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UREs  ON  Appendicitis 


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http://www.archive.org/details/lecturesonappend1897morr 


HOW   WE   TREAT    WOUNDS    TO-DAY. 


ROBERT  T.  MORRIS,  M.D. 


NEW  EDITION  REVISED.       i6mO,  CLOTH.       PRICE  $I.OO 


The  book  is  so  thoroughly  practical  that  it  must  be  commended  to  those 
who  wish  to  acquire  an  exact  knowledge  of  the  details  of  antiseptic  treat- 
ment.— Bost.  Mid.  and  Surg,  your.^  1886. 

Mais  ce  rapide  apergu  ne  peut  donner  qu'  une  idee  fort  insufKsante  de 
ce  precieux  petit  traits,  et  nous  ne  saurions  trop  en  recommander  la 
lecture. — Revue  de  Ckirurgie,  Dec.  10,  1886. 


G.   P.  PUTNAM'S    SOX?,  Publishers,  New  York  and  London. 


LECTURES  ON  APPENDICITIS 


AND 


NOTES  ON  OTHER  SUBJECTS 


BY 


ROBERT    T.  MORRIS,  A.M.,  M.D. 

Fellow  of  the  New  York  Academy  of  Medicine,  American  Association  of  Obstetricians 

and  Gynecologists,  American  Medical  Association  ;  Member  of  the 

New  York  State  and  County  Medical  Societies,  Society     . 

of  Alumni  of  Bellevue  Hospital,  Linnean 

Society  of  Natural  History,  etc. 


SECOND  EDITION,  RE  VISED  AND  ENLARGED 


With  Illustrations  by  Henry  Macdonald,  M.D. 


G.  P.  PUTNAM'S  SONS 

NEW   YORK  LONDON 

27   WEST  TWENTV-THIRD   STREET  24   BEDFORD   STREET,  STKAND 

£^£  linichcrbodur  |1rrss 
1897 


'/>e6  {>/ 


Copyright,  1S95 

BY 

G.  P.  PUTNAM'S   SONS 


Ube  1kntct!erbocf?er  ipresB,  IRcw  IROcbellc,  m,  !3« 


-ox 


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PREFACE. 


4i 


Eight  years  ago,  when  there  was  confusion  in  antiseptic 
methods  of  wound  treatment,  I  presented  a  httle  book,  which 
was  accepted  because  it  told  of  one  way  for  accomplishing 
certain  ends.  At  the  present  time,  while  there  is  confusion  of 
ideas  on  the  subject  of  appendicitis,  it  is  perhaps  a  favorable 
time  for  blazing  one  clear  trail  through  the  subject  in  a  similar 
way.  In  the  matter  of  operative  procedures,  I  have  due  respect 
for  methods  which  are  different  from  my  own,  believing  that  in 
the  art  of  surgery  every  surgeon  is  a  law  unto  himself,  and  that 
he  knows  the  factors  of  his  own  success.  This  collection  of 
lectures  includes  the  substance  of  my  teaching  on  the  subject  of 
appendicitis  at  the  Post-Graduate  Medical  School  in  New  York, 
and  I  have  added  a  series  of  notes  on  other  subjects  which  have 
received  little  attention  in  literature,  but  which  have  interested 
my  class. 

The  terms  local  leucocytosis  and  phagocytosis  I  have  used 
synonymously,  pending  further  investigation.  The  substance  of 
many  of  the  notes  has  appeared  in  various  periodicals — e.g.,  the  New 
York  Medical  Journal  and  Nezv  York  Medical  Record,  the  Annals 
of  Surgery,  the  New  England  Medical  Monthly,  the  Post-Gradiiate, 
the  Transactions  of  the  American  Association  of  Obstetricians  and 
Gynecologists,  Transactions  of  the  Southern  Surgical  and  Gyneco- 
logical Association,  Transactions  of  the  American  Medical  Asso- 
ciation, Transactions  of  the  International  Medical  Congress  at 
Berlin,  i8go.  Transactions  of  the  New  York  State  Medical  Society, 
Transactions  of  the  Pan-American  Medical  Congress. 

Aid  in  research  work  was  given  by  Dr.  Arnold  Eiloart  and 
C.  N.  Haskell,  in  chemistry  ;  and  by  Drs.  J.  C.  Smith,  H.  T. 
Brooks,  and  William  Vissman,  in  pathology.  Dr.  J.  C.  Smith 
furnished  the  photo-micrographs,  and  the  illustrations  from  my 
specimens  and  dissections  were  made  by  Dr.  Henry  Macdonald. 


CONTENTS. 


CHAPTER  I. 

,  PAGE 

Preparation  of  Surgeon  and  Patient     ...„,.  I-9 

CHAPTER  II. 
The  Appendix  Vermiformis  Ceci         ...,».         10-15 

CHAPTER  III. 

Appendicitis    <,  ,...,,,  .         16-48 

CHAPTER  IV. 
Surgical  Treatment  of  Appendicitis    ......         49-83 

CHAPTER  V. 

The  Action  of  Various  Solvents  on  Gallstones  ....  84-91 

The  Influence  of  Remains  of  the  Embryonic  Vitelline  Duct  in  the  Produc- 
tion of  Moist  Navels,  and  of  Eczematoid  Inflammation  about  the  Navel         92-93 

Malignant  Islands  at  the  Navel  Occurring  Simultaneously  with  Malignant 
Disease  of  the  Abdominal  or  Pelvic  Organs 

A  Last  Resort  Hernia  Operation         ..... 

The  Experimental  Production  of    Ileal  Intussusception  with  Carbonate  of 
Sodium     ........ 

The  Reason  why  Patients  Recover  from  Tuberculosis  of  the  Peritoneum 

The  Prevention  of  Secondary  Peritoneal  Adhesions  by  Means  of  an  Aristol 
Film  ........ 

Another  Method  for  Palpation  of  the  Kidney  .    '  .      '        . 

Experiments  Germane  to  the  Subject  of  Abdominal  Supporters  after  Laj 
arotomy    ........ 

An  Addition  to  McGuire's  Operation  for  a  Supra-Pubic  Urethra 

The  Drainage  Wick    ....... 

Endoscopic  Tubes  for  Direct  Inspection  of  the  Interior  of  the  P>ladder  and 

Uterus       .  .  .  .  .  .  .  .  .117-119 


94-97 
98-99 

I 00-101 
102-104 

105-106 
107-10S 

109-1 I I 
112-114 
11=;- 1 16 


VI 


Contents. 


The  Action  of  Trypsin,  Pancreatic  Extract,  and  Pepsin,  upon  Slouglis  and 

Coagula     ......... 

The  Removal  of  Necrotic  and  Carions  Bone  with   Hydrocliloric  Acid  and 

Pepsin       ........ 

Is  Evohition  Trying  to  Do  Away  with  the  Clitoris?  , 

The  Mechanism  and  Anatomy  of  Subluxation  of  the  Head  of  the  Radius 

Pott's  Fracture,  and  the  Fracture  of  tlie  Fibula  which  follows  Adduction  o 

the  Foot   ........ 

The  Dowel-Pin  in  Dislocation  of  the  Acromial  End  of  the  Clavicle  . 
The  Dowel-Pin  in  Fracture  of  the  Clavicle 
Mallet-Finger  .... 

Two  Cases  of  Conservative  Surgery  of  the  Arm 

Skin  Grafting  from  Blisters 

Phelps's  Flare-Lip  Operation  in  Two  Steps     . 

Distension    of    Fistulous    Pipes   with    Plaster    of    Paris    to    Facilitate    thei 

Removal  ........ 

Prevention  of  Abortion  by  Removal  of  a  Uterine  Fibroid 

Reduction  of  an  Inverted  Uterus  by  Incising  the  Constricting  Ring  Intra 

abdominally 
Hysterectomy  for  Placenta  Previa 
Ovarian  Transplantation 
Healing  through  the  Agency  of  Blood  Clot 
Subsequent  Notes  on  Appendicitis 
F-ormalin  Catgut 

INDEX 


123-125 
1 26-1 3 1 
132-135 

136-13S 

139-141 
142 

143-145 

146-150 

151-152 

153 

154 
154 

155 
155 
156-159 
161 
162 


171 


LIST  OF  ILLUSTRATIONS. 


Culture  tube    .... 

Portable  set  of  culture  tubes   . 

The  appendix  vermiformis  ceci 

Concretions     .... 

Section  of  normal  appendix    . 

Section  of  infected  appendix  . 

Section  of  normal  mucosa  and  lymphoid  layer  of  appendix 

Section  of  appendix  undergoing  destruction 

Acute  ulceration  of  appendix 

Chronic  ulceration  of  appendix 

Lymph  space  infiltration 

Thrombus  in  mesappendix 

Proliferating  endarteritis 

Round  sloughs  of  appendix 

Round  slough  of  appendix 

Gangrenous  appendix 

Gangrene  of  mesappendix 

Perforated  appendix 

Multiple  perforations  of  appendix  . 

Appendix  living  by  adhesion  circulation 

Interval  cases  ..... 

Adhesion  band  snaring  bowel 

Rhexis  of  appendix         .... 

Tenacula  stretching  skin 

Guy  line  ..... 

Aponeuroses  involved  in  appendix  operations 

Evanescent  scar 

Embryonic  remains  at  the  navel 

Adeno-carcinoma  of  navel 


6 

7 

lO 

13 
16 
16 
18 
19 

21 
21 

22 

23 

24 

23 
26 

27 
28 
29 
29 
30 
31 
32 

34 
54 
55 
56,  57 
.  61 

92,94 
95,  96 


vm 


List  of  IlliLstrations. 


Bowel    fastened  at  hernial  opening 
Ileal  intussusception 
Supra-pubic  urethra 
Drainage  wick 
Endoscopic  tubes    . 
Decalcified  bone     . 
Section  of  normal  clitoris 
Section  of  adherent  clitoris 
Orbicular  ligament 
Dislocation  of  clavicle     . 
Dislocation  of  clavicle  reduce 
Fracture  of  clavicle 
Mallet-finger    . 
Injured  and  repaired  arms 
Blister  graft     . 
Transplanted  ovarian  tissue 


PAGE 

•  99 

.  101 

112,  113 

.  116 

•  117 

124,  125 

.  126 

127,  12S 

•  132 

•  139 

.  140 

.  142 

143, 144, 145 

146, 

147,  148,  149,  150 

.151 

. 

157,  158 

LECTURES  ON  APPENDICITIS 


LECTURES  ON  APPENDICITIS 


CHAPTER  I. 

PREPARATION  OF  SURGEON  AND  PATIENT. 

General  Cleanliness  is  obtained  by  washing  our  hands,  and  the 
skin  of  the  patient,  at  the  proposed  field  of  operation,  with  ordi- 
nary soap  and  water,  aided  by  a  nail-brush. 

Special  Cleanliness  for  the  surgeon  and  assistants  is  gained  by 
immersing  the  hands  in  1:2000  bichloride  of  mercury  solution  for 
five  minutes  in  preparation  for  ordinary  work.  Theoretically,  this 
-does  not  completely  sterilize  the  hands,  but  practically  it  has  been 
sufficient  in  my  experience.  It  is  difificult  to  destroy  absolutely 
the  spores  of  some  of  the  bacteria,  but  if  the  whole  operation  is 
properly  conducted,  we  need  hardly  fear  the  few  spores  which  re- 
sist the  action  of  the  bichloride  on  our  hands.  After  operation 
upon  a  distinctively  septic  case,  and  before  proceeding  to  the  next 
one,  the  hands  are  prepared  by  immersing  them  in  a  solution  of 
permanganate  of  potassium,  one  drachm  to  the  pint,  until  they 
are  deeply  stained,  and  then  bleaching  them  in  a  solution  of  oxalic 
acid,  two  drachms  to  the  pint,  and  afterward  rinsing  in  1:2000 
bichloride  of  mercury  solution. 

Special  cleanliness  for  the  skin  of  the  patient  is  obtained  by 
methods  employed  for  cleansing  the  hands,  but,  in  addition,  the 
skin  is  always  shaved  first,  and,  if  possible,  a  pad  of  moist  bichlo- 
ride gauze  is  kept  in  contact  with  the  skin  at  the  proposed  field  of 
operation  for  ten  hours. 

Special  cleanliness  of  the  alimentary  canal  of  the  patient  is  aimed 
at  by  emptying  the  bowels,  and  then  giving  five  grains  of  salol. 
This  is  an  important  measure  in  abdominal  work,  because  the 
process  of  digestion  stops  when  the  abdominal  sympathetic  nerves 
are  shocked,  and  fermentation  ensues,  poisoning  the  patient  with 
saprophytic  products.     Salol  lessens  fermentation. 


2  Lectures  on  Appendicitis. 

Iiistriujicnts  are  sterilized  by  boiling  for  ten  minutes  in  i:ioo 
bicarbonate  of  sodium  solution.  The  boiling  sterilizes,  and  the 
bicarbonate  of  sodium  prevents  oxidation  of  the  bright  metal 
and  of  the  cutting  edges.  At  the  time  of  the  operation,  instru- 
ments are  allowed  to  remain,  while  not  in  use,  in  boiled  water. 

Towels  are  sterilized  by  boiling  for  ten  minutes  just  before  using,, 
if  they  were  boiled  for  half  an  hour  after  use  at  a  previous  opera- 
tion. 

Sponges. — Reef  sponges,  costing  less  than  two  dollars  a  pound, 
are  used  in  my  work.  They  are  soaked  in  warm  water  for  a  day 
to  soften  the  dry  sarcode  which  covers  the  spicules.  After  a  gen- 
eral washing,  they  are  placed  in  hydrochloric  acid  solution,  one  part 
to  ten,  and  left  there  until  all  shell  sand  is  dissolved.  Ten  hours 
will  suffice  for  some  of  the  sponges,  but  an  addition  of  acid  will  be 
necessary  if  the  original  amount  is  used  up  on  excessively  abun- 
dant lime  salts.  The  cleansed  sponges  are  placed  in  permanganate 
of  potassium  solution,  i:ioo  for  ten  minutes,  and  are  afterwards 
rinsed  before  going  into  the  bleach  bath  of  oxalic  acid  solution, 
1:30.  As  soon  as  they  are  white,  a  few  minutes'  immersion  being 
sufificient,  the  ones  that  are  wanted  for  early  use  are  immersed  in 
1:4000  bichloride  of  mercury  solution,  containing  glycerine  in  the 
proportion  of  one  ounce  to  the  pint,  and  they  are  left  in  the  solu- 
tion for  ten  hours.  After  being  squeezed  dry,  they  are  placed  in 
glass  jars  ready  for  use.  Sponges  that  are  not  to  be  used  for  sev- 
eral months  are  stored  dry,  tied  up  in  paper  bags.  A  repetition 
of  the  treatment,  minus  the  hydrochloric  acid,  will  answer  for 
sponges  that  have  been  used.  The  permanganate  of  potassium 
combines  with  the  organic  sarcode,  and  stains  the  inorganic  spic- 
ules, acting  as  a  germicide.  The  oxalic  acid  decomposes  the 
potassium  compounds,  and  is  destructive  to  bacteria  and  their 
spores.  The  bichloride  of  mercury  acts  further  as  a  germicide, 
and  glycerine  is  employed  because  it  is  hygroscopic,  and  prevents 
for  several  weeks  the  change  of  the  bichloride  of  mercury  to  calo- 
mel—  a  change  which  occurs  rapidly  when  dry  bichloride  is  ex- 
posed to  the  air  in  thin  layers  over  the  spicules.  If  a  strong 
solution  of  bichloride  of  mercury  is  used,  it  makes  the  sponges 
too  hard. 

Gauze. — Absorbent  gauze,  which  constitutes  the  principal  bulky 
dressing,  is  prepared  by  boiling  cheesecloth  or  mull  in  a  solution 
of  carbonate  of  sodium  (washing  soda)  i:i6,  for  two  hours:  chan- 
ging the  water,  rinsing,  and  boiling  again  in  the  same  solution  for 


Preparation  of  Sztrgeo7i  and  Patient.  3 

two  hours,  then  rinsing  and  boiling  in  pure  water  for  ten  minutes. 
The  gauze  is  then  absorbent,  because  the  soda  has  saponified  the 
fat  and  broken  up  the  gummy  elements  of  the  cotton  fibre.  The 
gauze  is  finally  washed  in  clean  boiling  water,  and  immersed  in 
1 :2000  bichloride  of  mercury  solution,  containing  one  ounce  of  gly- 
cerine to  the  pint.  After  squeezing  dry,  the  proportion  of  the  lot 
that  is  likely  to  be  used  in  less  than  two  months  is  stored  in  glass 
jars,  but  the  remainder,  as  with  the  sponges,  should  be  securely 
tied  up  in  paper  bags,  and  again  immersed  in  bichloride  and  gly- 
cerine before  being  placed  in  the  jars  for  early  employment. 

Iodofo7'vi  Gauze  \%  not  used  in  my  clinic  for  wound  treatment,  be- 
cause the  iodoform  and  the  fixing  agents  interfere  with  the  capil- 
larity of  the  gauze,  and  thereby  destroy  the  nice  mechanical  action 
which  is  the  chief  and  great  virtue  of  gauze  dressings. 

Absorbent  Cotton  can  be  prepared  from  cotton  batting  by  the 
process  employed  for  gauze,  and  it  makes  a  much  cheaper  dress- 
ing, but  the  absorbent  cotton  does  not  look  attractive  unless  it  is 
re-carded  after  treatment,  and  on  that  account  is  not  often  manu- 
factured by  the  surgeon  at  home.  If  the  absorbent  gauze  and 
cotton  are  purchased  from  dealers,  each  lot  must  be  tested  sepa- 
rately, because  a  patient's  life  is  often  staked  absolutely  upon  the 
capillarity  of  a  filament  of  gauze,  and  I  have  bought  alleged  ab- 
sorbent dressings  which  would  have  betrayed  the  patient's  trust 
in  me.  Test  absorbent  gauze  and  cotton  by  dipping  one  end  of 
the  filament  of  prepared  and  unprepared  stuff,  side  by  side  into  a 
glass  of  warm  water.  The  water  will  be  seen  to  shoot  up  into  the 
absorbent  stuff  instantly. 

Drainage  Apparatus. — Drainage  is  not  often  required  for  aseptic 
wounds,  but  it  has  a  place  of  vital  importance  at  times.  I  depend 
almost  entirely  upon  the  drainage  wick,  made  by  rolling  absorb- 
ent gauze  in  gutta-percha  tissue,  very  much  as  one  rolls  tobacco 
in  a  cigarette  paper.  The  average  wick  is  about  the  diameter  of 
a  cigarette,  but  longer.     (See  article  on  Drainage  Wick.) 

Sutures  and  Ligatures. — Silk  is  used  by  me  in  one  place  only 
in  surgery,  and  that  is  for  ligating  the  inner  tube  of  the  appendix. 
The  tiniest  of  buried  knots  is  desirable  at  that  point,  and  the 
finest  strand  of  silk  answers  the  purpose  well.  The  silk  is  boiled 
for  half  an  hour,  and  then  stored  on  a  glass  rod  in  a  glass  tube 
filled  with  alcohol. 

Catgut. — Catgut  is  the  ideal  material  for  sutures  and  ligatures, 
if  prepared  according  to  the  following  directions:   Every  surgeon 


4  Lect2ircs  on  Appendicitis. 

must  attend  personally  to  the  preparation  of  his  catgut.  No 
matter  how  good  the  intention  of  the  dealer,  the  work  is  some- 
times given  to  workmen  who  do  not  know  what  responsibility 
they  are  to  share  with  the  surgeon,  and  the  patient's  needle  may 
turn  on  a  pivotal  suture.  I  buy  from  L.  H.  Keller  &  Co.,  64 
Nassau  Street,  New  York,  the  hanks  of  raw  catgut  in  the  form 
known  as  "bow-lines."  Each  bow-line  is  one  metre  in  length, 
and  the  form  is  convenient  because  a  few  strands  can  be  removed 
from  the  storage  bottle  and  placed  in  a  saucer  of  alcohol  at  the 
time  of  the  operation,  thus  avoiding  the  danger  of  contaminating 
the  mass  remaining  in  the  storage  bottle.  Different  dealers  num- 
ber their  sizes  of  catgut  arbitrarily,  and  in  order  to  establish  a 
standard  I  have  proposed  that  the  American  Standard  Wire 
Gauge  be  used.  Such  a  gauge  can  be  found  in  almost  any  me- 
chanic's shop,  and  there  is  no  good  reason  why  catgut  should  not 
be  measured  by  this  standard.  The  sizes  that  are  employed  for 
almost  all  of  my  work  are  No.  25  and  No.  20,  American  wire 
gauge.  The  hanks  of  raw  catgut  are  placed  in  a  glass  jar  and 
freely  covered  with  commercial  sulphuric  ether,  in  which  they 
remain  for  a  week.  The  ether  removes  the  fixed  oil,  and  acts  as 
a  germicide,  becoming  very  foul,  however,  and  unfit  for  further 
use.  The  foul  ether  is  poured  off  at  the  end  of  a  week,  and  fresh 
ether  containing  bichloride  of  mercury,  in  the  proportion  of 
I  14000,  is  added.  After  standing  in  this  new  ether  for  a  week, 
the  hanks  are  transferred  to  a  storage  bottle  of  absolute  alcohol, 
containing  bichloride  I  ".4000,  and  are  ready  for  use,  unless  the 
chromicizing  process  is  preferred.  I  use  cliromic  gut  altogether, 
because  smaller  sizes  of  this  will  take  the  place  of  clumsy  strands 
of  simply  prepared  gut.  To  chromicize  the  catgut,  it  is  first  pre- 
pared by  the  simple  process,  and  is  then  placed  in  a  solution  of 
bichromate  of  potassium  and  alcohol,  fifteen  grains  to  the  pint, 
first  dissolving  the  bichromate  in  one  ounce  of  distilled  or  boiled 
water,  and  adding  it  to  the  alcohol  in  the  form  of  a  watery  solu- 
tion. The  catgut  remains  in  the  solution  of  bichromate  of  potas- 
sium and  alcohol  for  fifteen  hours,  and  is  then  drained,  and  placed 
in  absolute  alcohol  for  storage.  The  chromicizing  process  doubles 
the  resistance  to  absorption  of  the  catgut  in  the  tissues.  When 
first  prepared,  the  resistance  is  not  quite  doubled,  and  after  stand- 
ing in  the  alcohol  for  a  year,  it  is  rather  more  than  doubled  ;  but 
this  variation  is  of  little  practical  importance.  Catgut  left  in  the 
bichromate  of  potassium  solution  for  more  than  fifteen  hours  be- 


Preparation  of  Surgeon  and  Patient.  5 

comes  too  resistant,  and  may  not  be  absorbed  in  months.  Pre- 
pared for  fifteen  hours  in  the  fifteen-grain-to-thc-pint  solution,  No. 
25  is  absorbed  in  about  ten  days,  and  No.  20  in  about  twenty 
days.  At  the  time  of  the  operation,  a  sufficient  number  of  bow- 
lines are  removed  from  the  storage  bottle,  and  placed  in  a  saucer 
of  alcohol  ready  for  immediate  use.  Any  bow-lines  left  over  after 
the  operation  are  thrown  away.  After  preparing  a  lot  of  catgut, 
it  is  tested  by  cutting  up  a  strand,  placing  the  pieces  in  boiled 
distilled  water  for  ten  minutes,  and  then  planting  the  pieces  in  a 
test  tube  of  agar-agar. 

Irrigating  Solutions. — The  only  irrigating  solutions  that  I  em- 
ploy are  physiological  saline  solution  and  strong  hydrogen 
dioxide. 

Hydrogen  Dioxide  is  used  in  full  strength  for  flushing  septic 
cavities  at  the  time  of  the  operation,  and  is  then  washed  out  with 
the  physiological  saline  solution.  The  dioxide  of  hydrogen  is  a 
powerful  germicide,  and  it  not  only  destroys  the  bacteria,  but 
throws  up  pus  and  septic  fluids  in  a  foamy  mixture,  which  is 
easily  washed  away.  The  same  antiseptic  is  used  in  many  septic 
cavities  after  operation  until  granulation  begins,  but  we  must  dis- 
continue its  use  then,  as  a  rule,  because  the  peroxide  follows  leu- 
cocytes into  granulation  tissue,  and  thus  delays  repair. 

Physiological  Saline  Solution,  representing  the  normal  propor- 
tion of  chloride  of  sodium  in  the  blood,  is  the  least  irritating  and 
the  most  useful  general  irrigating  solution.  It  is  made  by  boiling 
ninety  grains  of  chloride  of  sodium  in  one  quart  of  water. 

Common  Boiled  Water  irritates  the  tissues,  and  is  somewhat 
corrosive,  as  may  be  observed  by  dropping  it  on  the  eye,  or 
placing  a  glistening  piece  of  peritoneum  in  it  for  an  hour.  Water 
in  the  eye  causes  smarting,  and  it  dulls  the  surface  of  the  peri- 
toneum. In  a  peritoneal  operation  it  injures  the  serosa  slightly, 
and  may  cause  vexatious  little  adhesions  afterward.  The  injury  to 
the  serosa  may  besufUcient  to  close  the  mouths  of  the  lymphatics 
upon  which  the  surgeon  depends  for  very  important  aid  in  carry- 
ing off  septic  matter.  Therefore  unsalted  water  should  not  be 
used  for  irrigating  purposes. 

Chem.ieal  Antiseptic  Solutions  are  still  more  irritating  than  plain 
water.  We  depended  upon  them  until  progress  carried  us  to 
aseptic  surgery.  Physiological  saline  solution  is  used  for  all  ordi- 
nary purposes  of  irrigation  in  surgical  work,  and  it  is  practically 
unirritating.  The  sponges  are  kept  in  basins  of  it  at  an  operation, 


Led  tires  on  Appendicitis. 


and  the  surgeon's  hands  are  washed  in  it  for  neatness'  sake  while 
he  is  at  work. 

Aristol. — Aristol  is  similar  to  iodoform  in  its  action,  but  it  is 
preferable  to  iodoform  because  it  adheres  to  tissues  much  more 
tenaciously;  because  it  seldom,  if  ever,  produces  any  toxic  efTects, 
and  because  it  smells  better.  Aristol  is  not  directly  an  antiseptic, 
but  it  quickly  forms  with  lymph  a  thin  protect- 
ing coagulum  which  is  almost  impenetrable  to 
bacteria.  The  free  iodine  which  is  given  off, 
destroys  irritating  ptomaines,  and  allows  leuco- 
cytes to  marshal  their  forces  on  one  side  of  the 
coagulum  wall,  while  bacteria  are  making  slow 
progress  from  the  other  side.  Aristol  is  of  the 
utmost  importance  in  closing  tissue  planes 
against  infiltration  from  a  wound.  For  instance, 
after  supra-pubic  cystotomy,  it  will  make  a  fine 
impenetrable  wall  about  the  drainage  track. 
It  will  do  the  same  thing  after  the  removal  of 
the  gangrenous  appendix,  or  a  pus  tube,  and  it 
makes  very  simple  the  question  of  drainage 
after  operations  upon  the  gall-bladder  and  bile 
ducts.  The  comfort  that  I  find  in  the  use  of 
aristol  according  to  a  proper  technique  is  very 
decided.  The  drug  must  be  studied  with 
reference  to  its  use  in  forming  a  thin  protecting 
coagulum.  Aristol  is  apparently  not  absorbed 
readily  in  the  tissues,  but  it  becomes  harmlessly 
encapsulated.  In  rabbits  upon  which  1  experi- 
mented, and  in  operations  upon  patients  in 
whom  I  had  previously  employed  it  for  prevent- 
ing secondary  peritoneal  adhesions,  the  aristol 
was  found  encapsulated  in  little  spots,  retaining  its  color,  and 
producing  an  appearance  which  will  puzzle  pathologists  who  come 
across  it  without  knowing  that  aristol  has  been  used  in  the  case. 
Aprons. — A  very  thin  and  light  apron  of  rubber  dam  with  rub- 
ber tube  strings,  is  made  for  me  by  John  Reynders  &  Co., 
of  New  York.  These  aprons  can  be  packed  in  very  small  space, 
and  they  are  boiled  and  otherwise  cleansed  with  ease.  One  of  the 
aprons  rolled  over  a  rope,  and  leaving  half  of  the  apron  free,  can 
be  tied  about  the  waist  of  a  patient  in  Trendelenburg's  posture. 
Used  in  this  way  it  keeps  the  clothing  of  the  patient  dry,  and 
conducts  fluids  into  a  proper  receptacle. 


Fig.  I. 
Culture  Tube. 

A,  cotton  plug. 

B,  swab  carrier. 

C,  swab. 

D,  agar-agar. 


Preparation  of  Surgeon  and  Patient.  7 

CulUirc  Tubes.— Yowx  or  five  culture  tubes  of  agar-agar  arc  car- 
ried in  a  little  case  in  my  instrument  bag.  A  swab  fastened  to  a 
copper  wire  rests  in  the  tube,  not  quite  touching  the  culture 
medium.  The  mouth  of  the  tube  is  filled  with  scorched  cotton. 
At  an  operation  in  which  it  is  interesting  to  note  what  species  of 


Fig.  2.— rortable  set  of  culture  tubes  for  the  surgeon's  bag. 

bacteria  have  been  at  work,  the  swab  is  touched  against  the  in- 
fected tissues,  and  then  carried  to  the  agar-agar.  The  swab^  is 
then  thrown  away,  and  the  mouth  of  the  tube  again  plugged  with 
scorched  cotton,  after  which  the  tubes  are  handed  to  the  bacteri- 
ologist for  further  investigation. 


8  Lectures  on  Appetidicitis. 

Results. — The  efficiency  of  the  comparatively  simple  resources 
above  described  is  shown  very  well  in  one  of  the  hospitals  at 
which  I  have  none  of  the  complete  advantages  which  are  furnished 
at  our.  Post-Graduate  Hospital,  and  in  other  hospitals  in  New 
York,  where  my  patients  receive  elaborate  preparatory  treatment 
and  detailed  after-treatment  under  my  personal  supervision.  I 
refer  to  the  Ithaca  City  Hospital,  which  is  a  transformed  woodert 
dwelling-house,  having  meagre  advantages  as  a  hospital.  Almost 
none  of  my  patients  there  received  any  preliminary  treatment^ 
but  were  prepared  on  the  day  of  the  operation,  and  frequently  on 
the  operating-table  only.  I  saw  most  of  these  patients  for  the 
first  time  then,  and  not  again  afterward.  The  medical  staff  con- 
sists of  a  large  number  of  physicians  and  surgeons,  and  yet  during- 
a  period  of  two  years  there  has  been  but  one  death  among  the 
surgical  cases  at  that  hospital  in  the  service  of  any  of  the  oper- 
ators. That  death  occurred  after  a  hip-joint  amputation  in  one  of 
my  patients  who  had  suffered  for  years  with  suppuration  from  the 
whole  length  of  the  femur,  following  osteo-myelitis,  and  who  had 
amyloid  kidneys  and  puffy  feet  on  the  day  of  operation.  I  am  at 
liberty  to  give  my  own  statistics  only.  From  the  hospital  years 
February  6,  1893,  to  February  6,  1895,  I  operated  upon  the  fol- 
lowing 193  cases,  in  178  patients,  at  the  Ithaca  Hospital.  No' 
patients  were  refused  operation  excepting  hopeless  cases  of  carci- 
noma and  sarcoma,  and  exploratory  operations  were  done  in  five 
cases  of  this  sort  to  determine  if  an  involved  organ,  such  as  the 
gall-bladder  or  intestine  could  possibly  be  operated  upon  with  a 
prospect  of  benefit  to  the  patient. 

Acute  appendicitis  ;  perforation  of  cecum  ;  abdomen  distended  with  pus  and  gas, 

not  encapsulated r 

Acute  appendicitis  ;  perforation  opening  into  abscess  cavities,  encysted 4 

Acute  appendicitis  ;  mucosa  desquamating I 

Chronic  appendicitis  ;  various  adhesions  and  complications ir 

Typhlitis,  perforative  ;  abdomen  full  of  sero-pus i 

Abdominal  hysterectomy  for  very  large  myomata  and  fibromata 6 

Abdominal  hysterectomy  for  a  placental  hemorrhage i 

Vaginal  hysterectomy  for  cancer,  i  ;  procidentia,  i  ;   chronic  metritis,  3 5 

Abdominal  hystero-pexy  for  retroversion  of  uterus 5 

Abdominal  hystero-pexy  and  removal  of  destroyed    adnexa 6 

Removal  of  large  ovarian  cysts 6 

Celiotomy  for  conservative  treatment  of  adherent  or  diseased  adnexa  of  the  uterus, 

non-suppurative 7 

Celiotomy  for  removal  of  pyogenic  oviducts 2 

Exploratory  celiotomy  to  determine  if  malignant  growths  could  be  operated  upon.  5 

Gastrorrhaphy  for  chronic  dilatation  of  stomach r 

Bassini's  operation  for  hernia 2, 


Preparation  of  Surgeon  and  Patient.  9 

Macewen's  operation  for  hernia i 

Closure  of  ventral  hernial  opening 2 

Supra-pubic  cystotomy,  stone,  i  ;  tuberculosis,  i  ; 2 

Nephrorrhaphy  for  loose  kidney 3 

Removal  of  navel  for  eczema I 

Removal  of  breast  and  axillary  glands  for  cancer 11 

Repair  of  rupture  of  perineum. •. 7 

Repair  of  perineum  and  cervix  simultaneously 3 

Repair  of  cervix ....  2 

Removal  of  decomposed  fetus  5  months  (vaginal  route) i 

Von  Bergmann's  hydrocele  operation  (excision  of  sac) 4 

Lister's  varicocele  operation  (excision  of  veins) 14 

Ligature  of  dorsal  vein  of  penis  for  impotence 2 

Excision  of  varicose  veins  of  leg i 

Circumcision  for  phimosis 6 

Amputation  of  penis  for  cancer i 

Internal  urethrotomy  for  stricture 9 

Removal  of  sphacelus  of  bone,  tibia,  2  ;  femur,  i  ;  maxilla  i 4 

Amputation  of  forearm i 

Re-amputation  of  leg i 

Hip-joint  amputation  (death  immediately,  shock) I 

Amputation  of  thumb  for  sarcoma i 

Suture  of  fractured  ulna I 

Tenotomy  for  talipes 2 

Excision  of  tuberculous  tendon  of  biceps  brachialis i 

Suture  of  cut  tendons  of  hand  or  wrist 3 

Suture  of  dislocated  acromial  end  of  clavicle i 

Ligation  of  hemorrhoids 4 

Obliteration  of  fistula  in  ano 5 

Coccygectomy  for  coccygodynia 2 

Removal  of  sarcomatous  neuromata,  ulnar,  2  ;    circumflex,  i  ;  peroneal,  i 4 

Removal  of  melano-sarcoma  of  brachial  region i 

Mastoid  bone  opened  for  evacuation  of  abscess ; i 

Incision  for  periostitis  of  tibia i 

Extirpation  of  tuberculous  inguinal  bubo i 

Extirpation  of  tuberculous  mass  of  cervical  glands 3 

Extirpation  of  coccygeal  dermoid  cyst 2 

Extirpation  of  vulvar  fistulous  tract  for  embedded  hair-pin i 

Extirpation  of  hypertrophied  tonsils,  child,  i  ;  adult,  i i 

Plastic  operation  after  removal  of  cancer,  lip,  3  ;  cheek,  2 5 

Poncet's  operation  for  goitre i 

Removal  of  cancerous  glands  of  neck 2 

Removal  of  branchial  cyst  of  neck i 

Removal  of  large  fibroid  tumor  of  neck I 

Plastic  operation  on  anus,  incontinence  stricture 3 

Fracture  and  replacement  of  deviated  nasal  septa 2 

Removal  of  extensive  papilloma  of  anal  region  and  buttocks i 

Whole  number  patients,  178  ;  Operations,  193  ;  Deaths,  i-. 

The  reduction  of  a  general  surgical  death-rate  to  a   fraction  of 

one  per  cent,  under  such  circumstances  is  due  to  the  resources  of 
to-day  rather  than  to  any  particular  skill  on  my  part. 


CHAPTER  II. 

THE    APPENDIX   VERMIFORMIS    CECI. 

The  lengthened  cecum  of  mammals  has  degenerated  to  a 
vermiform  appendix  in  some  species.  The  cecal  appendage  is 
vermiform  in  man  and  in  all  of  the  man-like  apes — gorilla,  orang, 
chimpanzee,  and  gibbon  (several  species).  It  is  also  vermiform  in 
certain  lemurs,  and  perhaps  in  some  of  the  monkeys.  Curiously 
enough  the  marsupial  wombat   has  a  vermiform   appendix.     In 


Fig.  3. — Normal    appendix    vermiformis    ceci   {^Homo  sapiens)  showing   mesappendix 

and  solitary  artery. 

man,  the  cecal  appendage  is  apparently  a  rudimentary  structure 
which  once  formed  an  important  part  of  the  alimentary  tract  in 
the  days  when  we  needed  a  wisdom  tooth  for  crushing  palms  and 
ferns,  and  a  large  absorbing  surface    for   extracting   their  scanty 


The  Appendix  Vei'iniformis  Ceci.  1 1 

nutriment.  Now,  as  degenerate  structures,  the  cecal  appendix, 
and  the  wisdom  tooth,  with  its  insufficient  calcification,  perish 
easily  when  attacked  by  bacteria.  The  microscope  does  not  show 
the  comparative  vital  energy  of  different  cells  or  structures,  but 
it  is  fair  to  assume  that  the  unused  appendix  has  low  vitality, 
because  we  know  analogously  that  other  unused  normal  struc- 
tures lose  to  a  certain  extent  their  resistance  to  infection  by 
bacteria. 

The  appendix  vermiformis  in  man  was  recognized  as  a  struc- 
ture in  the  sixteenth  century,  and  was  described  in  the  eighteenth 
century.  It  appears  at  about  the  tenth  week  of  fetal  life.  As 
compared  with  the  length  of  the  colon,  it  is  largest  at  birth,  and 
smallest  after  seventy  years  of  age.  It  is  one  of  the  structures 
which  flutters  before  going  out  in  the  descent  of  man,  and  is  conse- 
quently of  extremely  variable  dimensions.  The  length  of  an 
average  appendix  vermiformis  in  a  young  adult  is  not  far  from 
three  and  three-quarter  inches,  with  a  diameter  of  the  quill  of  the 
primary  feather  from  the  wing  of  a  Canada  goose.  We  occa- 
sionally find  a  normal  appendix  two  inches  long,  or  eight  inches 
long,  and  I  have  removed  several  which  were  about  half  a  foot  long. 
Measurements  taken  post  mortcni  will  give  too  great  an  average 
length,  because  the  appendix  becomes  lax  and  elongated  after  the 
period  of  rigor  mortis  has  passed.  Measurements  taken  from 
specimens  removed  at  operation  will  give  too  short  an  average 
length,  because  the  structure  contracts  almost  immediately  on 
separation  from  the  cecum,  unless  it  is  gangrenous  or  tense  with 
exudates.  We  must  therefore  make  our  estimates  from  normal 
appendices  observed  while  we  are  engaged  in  other  abdominal 
work. 

The  position  of  the  appendix  is  usually  behind  the  cecum,  and 
pointing  toward  the  spleen,  but  its  tip  may  touch  almost  all 
boundaries  of  the  peritoneal  cavity.  It  is  ordinarily  supplied  with 
a  mesappendix,  which  is  given  off  from  the  left  layer  of  the 
mesentery  of  the  ileum.  There  is  good  authority  for  the  state- 
ment that  the  appendix  is  sometimes  extra-peritoneal,  but  in  all 
observations  by  myself,  in  which  structures  were  not  too  badly 
damaged  for  accurate  determination  of  that  point,  the  appendix 
possessed  a  mesappendix.  This  is  a  matter  of  little  practical  im- 
portance to  the  surgeon,  because  an  appendix  situated  behind  the 
peritoneum  could  be  easily  released  by  a  slit  through  the  peri- 
toneum at  that  point. 


1 2  Lectures  on  Appendicitis. 

A  transverse  section  of  the  appendix  shows  it  to  consist  of  the 
structures  which  belong  to  the  cecum,  but  with  an  excess  of 
lymplioid  tissue,  amounting  in  some  cases  to  half  of  the  entire 
mass.  From  without  inward,  the  layers  are  :  peritoneum,  external 
non-striated  circular  muscle,  internal  non-striated  longitudinal 
muscle,  lymphoid  tissue,  and  mucosa.  This  does  not  include  the 
connective-tissue  layers,  the  most  important  of  which,  lying 
between  the  lymphoid  tissue  and  the  longitudinal  muscle,  becomes 
so  greatly  distended  with  serum  as  to  form  a  strong  factor  in 
exudate  strangulation  of  the  lymphoid  layer  in  some  infected 
appendices; 

The  principal  arterial  supply  of  the  appendix  is  from  a  branch 
of  the  ileo-colic  artery,  which  passes  along  the  free  margin  of  the 
mesappendix.  This  artery  may  be  described  as  the  solitary 
terminal  artery  of  the  appendix,  and  its  anatomical  arrangement 
is  a  matter  of  great  clinical  importance.  In  some  women  the 
appendix  receives  a  little  collateral  circulation  by  way  of  the  ap- 
pendiculo-ovarian  ligament. 

The  lymphatics  of  the  appendix  pass  largely  to  a  ganglion  at 
the  cecal  extremity.  The  nerves  of  the  appendix  are  from  the 
superior  mesenteric  plexus  of  the  sympathetic  system,  which  is 
widely  distributed  to  the  small  intestine,  and  this  explains  the 
reason  why  patients  often  suffer  from  colic  and  general  abdominal 
pain,  or  pain  at  the  navel,  without  realizing  that  its  origin  is  at  a 
little  part  of  the  whole,  at  the  appendix  (Fowler).  It  is  almost 
an  exception  for  the  pain  to  be  localized  at  the  vicinity  of  the 
appendix  at  the  outset  of  an  attack  of  appendicitis. 

The  contents  of  the  appendix  usually  consist  of  mucus  with 
more  or  less  fecal  matter.  Under  ordinary  circumstances  semi- 
solid fecal  matter  and  gas  find  easy  entrance  to  and  exit 
from  an  appendix  with  a  large  lumen,  as  the  appendix 
has  abundant  muscular  ability  to  empty  itself,  and  it  has  at 
the  cecum  a  good  fixed  point  for  muscular  action.  It  is  not 
an  uncommon  sight  when  we  are  employed  in  abdominal 
work  to  see  an  appendix  empty  itself  of  distending  contents  when 
it  is  stimulated  to  contraction  by  the  touch  of  the  surgeon's  finger. 
Although  an  average  appendix  can  empty  itself  when  in  a  normal 
condition,  a  very  little  hyperplasia  or  swelling  of  the  lymphoid 
coat  will  suffice  to  lock  in  the  contents  of  the  lumen,  and  there 
are  very  many  normal  appendices  containing  concretions  which 
cannot  escape  because  the  lumen  is  too  small. 


The  Appendix  Vermifoinnis  Ceci.  13 

Appendix  concretions  are  of  three  j^rincipal  sorts — fecal,  phos- 
phatic,  and  fatty.  Fecal  concretions  are  formed  in  ncjrmal 
appendices  by  the  action  of  the  muscularis  rolling  a  bit  of  fecal 
matter  into  a  ball  or  rod,  which  is  cemented  with  mucus.  Insolu- 
ble salts  are  precipitated  out  of  the  fermenting  mucus,  and  as 
stagnant  mucus  is  very  apt  to  undergo  decomposition,  the  fecal 
concretions     are     usually     arranged    in    layers,    alternately    or 


Fig.  4. — Phosphatic  appendix  concretions. 
One  bisected,  showing  concentric  layers. 

homogeneously,  with  calcium  salts.  Phosphatic  concretions  are 
formed  in  normal  appendices,  and  in  chronically  infected  ap- 
pendices as  a  result  of  decomposition  of  mucus.  Phosphate  of 
calcium  is  the  common,  and  sometimes  the  only  ingredient  of  a 
concretion  which  may  become  as  large  as  a  hickory-nut.  Examina- 
tion of  three  typical  phosphatic  concretions  from  three  chronically 
infected  appendices  gave  the  following  results : 

(i)  Patient  had  repeated  slight  attacks  of  appendicitis  ;  con- 
cretion about  as  large  as  a  No.  T  shot  ;  color,  brown  ;  external 
layer  and  internal  portion  of  neutral  calcium  phosphate,  with 
traces  of  organic  matter  and  potassium  ;  no  magnesium  or  oxalic 
acid. 

(2)  Patient  had  repeated  attacks  of  appendicitis,  some  of  the 
attacks  violent.  Concretion  was  of  the  size  and  appearance  of  a 
date  seed  ;  grayish-brown  in  color  ;  external  layer  as  in  specimen 
No.  I  ;  internal  portion  contained  more  organic  matter. 

(3)  Patient  had  repeated  violent  attacks  ;  concretion  size  of 
robin's  egg  ;  of  a  whitish-clay  color ;  external  layer  and  internal 
portion  composed  of  fifty  per  cent,  of  fat  ;  the  remaining  fifty 
per  cent,  consisted  of  alkaline  calcium  phosphate. 

I  was  at  a  loss  to  account  for  the  large  proportion  of  fat  in  this 
and  in  other  similar  calculi,  but  it  seemed  possible  that  fatty 
metamorphosis  of  lymphoid  cells  in  a  chronically  ulcerating  ap- 
pendix might  furnish  enough  fat  to  make  a  concretion,  and  the 
following  analyses  were  accordingly  made,  the  inner  tubes  com- 


14  Lcctur'cs  oil  Appendicitis. 

posed  of  mucosa  and  submucosa  from  three  sets  of  appendices 
being  used  : 

(i)  Four  normal  appendices. 

Inner  tubes  dried  at   ioo°  ('.,  weit^hed    1. 0095  gm. 

And  yielded  fat  weighing 0.0860    " 


Percentage  of  fat S. 52 

(2)    Three  appendices  with  small  ulcerating  areas. 

Inner  tubes  dried  at  100°  C,  weighed 0.7276  gm. 

And  yielded  fat  weighing o.  1410     " 


Percentage  of  fat 19-38 

(3)    Three  appendices  ivitli  extensive  chronic  ulceration. 

Internal  coats  dried  at  100°  C,  weighed 0.6580  gm. 

And  yielded  fat  weighing o.  1 701    " 


Percentage  of  fat 25.S5 

The  inner  tubes  of  the  normal  appendices  weighed  dry  9.2  per 
cent,  more  than  those  of  the  ulcerating  appendices,  but  contained 
only  about  one  third  as  much  fat. 

Several  observers  have  reported  the  finding  of  gallstones  in 
appendices,  but  these  specimens  were  probably  appendix  stones. 
Even  though  the  composition  of  the  concretions  was  largely 
cholesterin,  it  is  a  tenable  belief  that  they  were  formed  in  chronic- 
ally ulcerating  appendices.  There  is  a  theory  extant  to  the 
effect  that  gallstones  are  formed  in  the  gall-bladder  by  the  pre- 
cipitation of  their  constituents  by  colon  bacilli,  the  bacteria  which 
are  constantly  present  in  ulcerating  appendices.  Appendix 
concretions  are  round,  oval,  flat,  or  rod-shaped.  Some  of  them 
occur  singly,  and  some  of  them  in  such  numbers  as  to  make  the 
appendix  look  like  a  rosary.  Various  kinds  of  seeds  are  closely 
simulated  by  these  concretions,  and  this  accounts  for  the  popular 
error  that  seeds  are  apt  to  get  caught  in  the  appendix.  The 
deception  is  all  the  more  complete  when  the  appendix  mucus 
becomes  condensed,  and  rolled  into  yellowish  prolongations  from 
the  concretions,  giving  almost  exactly  the  appearance  of  a  sprout 
from  a  seed.  I  have  not  as  yet  found  a  seed  in  any  of  the  appen- 
dices from  my  series  of  cases,  the  nearest  approach  to  one  being 
a  small  piece  of  apple  core  encrusted  with  phosphates.  The 
formation  of  fecal  and  phosphatic  concretions,  while  more  apt  to 


The  Appendix  Verniiforniis  Ceci.  1 5 

occur  perhaps  in  patients  whose  intestinal  contents  ferment,  may 
be  independent  of  any  disease  of  the  appendix  ;  but  fatty  con- 
cretions probably  occur  only  as  a  result  of  long  ulceration  of  the 
lymphoid  coat. 

Bacteria  are  by  all  means  the  most  important  things  found  in 
the  appendix.  The  colon  bacilli  which  have  their  normal  habitat 
in  the  colon  are  almost  invariably  present  in  the  lumen  of  the 
appendix,  and  they  are  harmless  dwellers  there  unless  an  infec- 
tion atrium  gives  them  an  opportunity  to  migrate  into  the  tissues. 
The  pyogenic  streptococci  are  also  pretty  constant  dwellers  in  the 
normal  appendix.  Many  of  the  less  important  pyogenic  bacteria 
and  saprophytes,  or  bacteria  of  fermentation,  harmlessly  lurk  in 
the  nook  of  the  appendix  awaiting  the  advent  of  conditions  which 
will  be  favorable  for  their  rapid  multiplication.  When  an  infec- 
tion atrium  is  made,  the  infection  is  at  first  mixed  in  character, 
as  observed  in  a  number  of  my  specimens  of  infected  appendices 
which  were  removed  in  the  very  early  stages  of  appendicitis. 
The  streptococci  are  apt  to  outstrip  other  bacteria  in  the  second 
part  of  the  race,  and  the  colon  bacilli  are  apt  to  lead  finally. 
Thriving  colonies  of  bacteria  are  daily  swept  along  through  the 
normal  colon,  and  are  moved  out  of  most  appendices ;  but  we 
must  always  look  at  the  appendix  as  a  test  tube  full  of  culture 
media,  and  forming  a  nook  in  which  bacteria  lurk  dangerously 
when  once  the  protecting  structures  of  the  appendix  have  been 
disabled.  Some  of  the  higher  entozoa  are  frequently  found  in  the 
appendix,  and  the  nematode  oxyuris  is  fond  of  making  it  a  nest. 


CHAPTER  III. 


APPENDICITIS. 


According  to  my  observations  to  date,  appendicitis  is  an 
infective,  exudative  inflammation  of  the  appendix  vermiformis 
ceci,  originating  in  any  local  cause  for  the  production  of  an  infec- 
tion atrium  in  the  tissues  of  the  appendix,  and  progressing  by 
bacterial  invasion  into  the  layers  of  connective  tissue,  and  the 
layer  of  lymphoid  tissue,  all  of  which  are  partially  or  completely 
disabled  by  interstitial  exudate  compression  within  the  narrow 


Fig.  5. — Section  of  air-distended  normal  appendix. 


Fig.  6. — Section  of  infected  appendix  which  was  becoming  disabled  from  interstitial 

exudate  compression. 

muscular  and  peritoneal  sheath  of  the  appendix.  The  principal 
cause  for  appendicitis  is  mixed  bacterial  infection  from  the  lumen 
of  the  appendix.  The  chief  cause  for  bacterial  infection  from  the 
lumen  of  the  appendix  is  the  formation  of  an  infection  atrium  in 
the  mucosa  of  the  appendix  by  force  applied  in  any  way.  I 
formerly  surmised  that  the  appendix  was  sometimes  injured  by 
pressure  between  a  full  cecum  and  the  hard  pelvic  wall,  supposing 
that  the  cecum  was  often  filled  with  fecal  matter  ;  but  after  exten- 
sive opportunities  for  observation,  I  have  not  as  yet  seen  fecal 

16 


Appendicitis.  1 7 

matter  in  the  cecum  at  any  operation,  and  tliere  is  doubt  if  so- 
called  impaction  is  not  often  lymph  exudate  instead.  Excepting 
in  elderly  people  I  believe  that  injury  to  the  mucosa  occurs  most 
often  from  accidental  twisting  of  the  appendix  upon  part  of  its 
long  axis.  An  infection  atrium  is  also  commonly  produced  by 
erosion  of  the  mucosa  at  the  site  of  a  concretion,  or  by  entozoa. 
Bacterial  infection  may  extend  into  the  tissues  of  the  appendix 
from  an  infected  cecum,  as  in  typhoid  fever  or  dysentery.  An 
infection  atrium  is  formed  in  its  peritoneal  outer  wall  at  times  by 
destruction  of  serosa  consequent  upon  peritonitis  extending  from 
adherent  infected  oviducts  or  other  near-by  structures. 

The  principal  structures  involved  in  appendicitis  may  be 
grouped  as  follows:  (i)  a  soft,  distensible  inner  tube  of  mucosa 
and  lymphoid  tissue  within  a  confining  outer  tube  of  muscle  and 
peritoneum  ;  (2)  lymphatics  leading  to  the  lymphatics  of  the  colon 
and  mesentery ;  (3)  veins  leading  to  the  superior  mesenteric 
vein  ;  (4)  a  solitary  terminal  artery;  (5)  connective-tissue  planes  ; 
and  (6)  nerves  belonging  to  the  mesenteric  plexus. 

The  above  definition  and  brief  statement  of  the  salient  points 
needs  some  repetition  and  elaboration.  The  mechanical  feature 
of  interstitial  serum  pressure  appears  as  soon  as  bacteria  have 
entered  an  infection  atrium — the  term  applied  to  any  gateway 
which  gives  entrance  for  bacteria  to  the  tissues.  The  toxines 
which  are  the  products  of  bacterial  growth  are  irritating,  and  as 
a  result  of  their  invasion,  serum  is  exuded  into  the  tissues  of  the 
appendix,  placing  such  tissues  under  the  influence  of  serum  com- 
pression. The  lymphoid  coat  of  the  appendix  and  its  connective- 
tissue  cushion,  forming  the  principal  part  of  the  inner  tube  of  the 
appendix,  are  so  much  like  the  faucial  tonsil,  that  I  shall  take  the 
liberty  of  speaking  of  the  one  as  the  tubular  tonsil,  and  of  the 
other  as  the  flat  tonsil,  for  purposes  of  illustration.  The  flat  ton- 
sil and  its  connective-tissue  cushion  can  swell  enormously  because 
there  is  a  whole  pharynx  to  give  room  to  them.  Even  then  the 
flat  tonsil  sometimes  fills  the  throat  and  its  connective-tissue 
cushion  sloughs.  The  infected  tubular  tonsil  and  its  connective- 
tissue  cushion  try  to  swell  just  as  the  flat  tonsil  does,  but  they  are 
promptly  subjected  to  pressure  within  the  narrow  confines  of  the 
muscular  and  peritoneal  tube  of  the  appendix.  The  imprisoned 
tube  is  then  further  compressed  by  contraction  of  the  muscular 
coat  upon  tlie  inner  tube,  in  tonic  spasm,  as  a  result  of  toxic 
stimulation  of  the  branches  of  Auerbach's  plexus.     Over-stimula- 


1 8  Lccttircs  oil  Appendicitis. 

tion  of  these  branches  leads  to  tonic  contraction  of  the  muscu- 
laris  at  the  appendix.  Stimulation  extending  to  the  branches  of 
Auerbach's  plexus  at  other  parts  of  the  intestine  leads  to  irregular 
spasm,  giving  the  symptom  known  as  colic,  and  if  over-stimulation 
of  the  sympathetic  system  extends  still  farther,  the  vaso-motors 
cause  the  heart  to  contract  rapidly  in  partial  spasm,  and  the  heart 
muscle  being  unable  to  relax  completely,  muscular  spasm  of  the 
arterioles  being  also  present,  the  result  is  a  small,  rapid  pulse.  The 
tonic  spasm  of  the  outer  tube  upon  the  inner  tube  of  the  appendix 
is  very  much  like  putting  a  tight  thimble  upon  a  finger  which  is 
already  tense  from  a  felon,  with  serum  exudate  under  the  perios- 
teum.    The  inner  tube  of  the  appendix  is  composed  of  the  same 


Fig.  7. — Section  of  normal  mucosa  and  lymphoid  layer  of  appendix  x  600. 

structures  as  the  inner  tube  of  the  cecum,  but  in  the  cecum  there 
is  abundance  of  room,  and  the  lymphoid  coat  continues  its  func- 
tion as  a  strainer  for  bacteria,  even  when  tense  with  interstitial 
exudates.  The  inner  tube  of  the  appendix,  on  the  other  hand^ 
anemic  from  compression,  cannot  strain  out  bacteria  well,  and  its 
cells  readily  undergo  toxic  destruction  from  bacteria.  The  in- 
fected appendix  with  its  lymph  and  blood  circulation  obstructed, 
is  not  reached  in  men  by  a  collateral  circulation  which  can  bring 


Appendicitis.  1 9 

poly-nuclear  leucocytes  to  throw  out  nuclcin,  and  c,n'vc  protection, 
and  consequently  the  bacteria  are  free  to  carry  r)n  destructive 
processes.  In  some  ulcerating  appendices  the  inner  tube  may  not 
be  swollen  enough  to  fill  the  lumen  of  the  appendix,  excepting 
when  irritation  of  the  muscular  sheath  excites  tonic  muscular 
spasm  of  that  sheath,  and  then  compression  anemia  again  dis- 
ables the  inner  tube.  Although  short  or  long  periods  of  muscular 
spasm  are  of  regular  occurrence  in  infected  appendices,  we  do  not 

'2 


Fig.  8. — Section  corresponding  to  Fig.  7,  but  undergoing  acute  toxic  destruction. 

1.  Free  border  once  occupied  by  mucosa. 

2.  Necrotic  area. 

3.  Broken-down  mucous  follicles. 

4.  Breaking-down  lymphoid  tissue  x  600. 

need  that  phenomenon  for  the  production  of  compression  anemia 
in  a  swollen  ring  of  lymphoid  tissue,  as  we  are  all  familiar  with 
the  mechanical  parallel  in  which  a  swelling  barrel  strains  against 
the  hoops — an  exaggerated  illustration,  but  one  in  which  the 
principle  is  the  same.  The  attacking  bacteria  which  are.  causing 
interstitial  exudation  in  the  appendix,  with  their  toxines,  may  be 
called  early  to  a  halt  by  the  processes  adopted  by  nature  for  stop- 
ping the  progress  of  bacteria  elsewhere.    Thus,  when  poly-nuclear 


20  Lectures  07i  Appendices. 

leucocytes  can  be  carried  freely  to  the  place  of  infection,  they 
pour  out  nuclein  in  large  quantities,  and  it  is  very  difficult  for 
bacteria  to  pass  the  nuclein  wall.  The  bacteria,  confined  within 
a  small  territory,  then  commit  suicide  with  their  own  tox- 
ines,  just  as  saccharomyces  commit  suicide  with  their  own 
alcohol  in  vinous  fermentation.  So  complete  is  this  destruction 
of  bacteria  that  an  appendix  lumen  closed  against  further  entrance 
of  bacteria  from  the  cecum  may  sometimes  become  distended 
with  sterile  serum  or  mucus.  The  appendix,  however,  is  particu- 
larly unfitted  to  receive  help,  because  when  its  single-artery  circu- 
lation is  blocked  by  interstitial  exudates  the  appendix  stands  out 
as  an  infected  peninsula,  cut  off  from  the  source  of  protection 
from  leucocytes,  and  the  bacteria  are  at  liberty  to  continue  with 
their  work  without  receiving  that  opposition  which  would  meet 
them  through  a  collateral  circulation  if  the  infection  were  in  the 
colon.  A  sufficient  degree  of  exudation  compression  having  cut 
off  the  access  of  leucocytes,  the  toxine  destruction  of  the  inner 
tube  of  the  appendix  progresses  to  various  degrees.  In  milder 
cases  there  is  simply  desquamation  of  patches  of  mucosa,  but  the 
injury  is  not  easily  repaired,  and  the  bacteria  lurking  in  such  a 
disabled  appendix  keep  up  a  certain  degree  of  malign  influence, 
sometimes  for  many  years,  though  the  patient  be  unaware  of  the 
fact.  Bacteria  in  the  lumen  of  the  appendix  are  ready  to  make 
new  incursions  at  any  favorable  moment,  so  that  the  appendix 
which  has  been  disabled  at  one  attack  of  appendicitis  may  be 
fairly  said  to  be  chronically  infected  afterward,  because  when  the 
bacteria  are  not  actually  in  the  tissues  of  such  an  appendix  during 
the  interval  between  attacks,  they  are  in  contact  with  an  exposed 
lymphoid  tube,  and  their  toxines  are  particularly  apt  to  maintain 
a  constant  influence  when  the  very  common  scar  constrictions  of 
the  lumen  of  the  appendix  lock  in  septic  mucus. 

Acute  mixed  infection  will  cause  all  of  the  acute  destructive 
processes  which  occur  in  the  appendix,  and  it  is  not  necessary  to 
look  for  any  specific  microbe  for  appendicitis.  I  have  obtained 
cultures  of  bacteria  from  appendices  removed  in  different  stages 
of  progress  of  the  disease,  and  although  the  colon  bacillus  was 
always  present,  the  infection  was  regularly  mixed  in  character  at 
first,  and  in  some  cases  up  to  the  last  point  of  destruction  of  tis- 
sues. As  previously  stated,  however,  there  is  a  very  decided  ten- 
dency on  the  part  of  the  streptococci  and  colon  bacilli  to  outstrip 
all   others,  and    finally  to  enter  into  a  race  with  each   other,  the 


Appendicitis. 


21 


colon  bacilli  usually  gaining  the  mastery.  That  is  why  appar- 
ently pure  cultures  of  colon  bacilli  are  often  found  in  the  large 
abscesses,  and  in  the  fluid  of  peritonitis  in  far  advanced  cases  of 
appendicitis,  giving  to 
such  collections  of  fluid 
their  disgusting  fecal 
odor,  which  is  really  the 
odor  of  products  of 
colon  bacilli.  The  ordi- 
nary odor  of  feces  is  due 
to  the  harmless  growth 
of  colon  bacilli  in  the 
bowel,  and  it  was  form- 
erly supposed  that  the 
odor  of  appendicitis  ab- 
scesses was  due  simply 
to  their  close  contact 
with  the  bowel.  It  was 
apparent,  however,  that 
the  odor  of  a  small  ap- 
pendicitis abscess  was 
sometimes  out  of  all  pro- 
portion to  its  size,  and 
it  Avas  found  that  ovi- 
duct abscesses  bearing 
the  same  relation  to  the 
bowel,  and  not  contain- fig.  io.— Chronic  ul- 

ing     cultures    of      colon    ceration  of  inner  tube, 

bacilli,  were    free    from   ^'"°™  '''^  ^"^^^'^^^  ^^^^ 

Tv/r-       J  u  of  appendicitis, 

fecal  odor.     Mixed  bac- 
teria   and    nearly    pure 
cultures   of    streptococci    are    destructive 
locally,  but  wide  infection    seems    to    be 
Fig.  9.— Destruction  of  inner  done   principally   by   the    flagellated,   far- 
tube   of   appendix  at  two  traveling  colon  bacilli,  which  may  appear 

points  by  acute  ulceration.     ....  ,  ,       .  , 

\\\  the  liver  or  lung  during  an  attack 
of  appendicitis.  The  colon  bacilli  when  once  aroused  seem 
like  a  swarm  of  angry  bees  about  an  over-turned  hive,  ready 
to  attack  anything  in  sight.  It  would  be  unwarrantable 
with  our  present  knowledge  to  ascribe  to  the  lowly  bacteria 
anything    so    high    as    nocturnal    habits,     and    yet    it    is    certain 


2  2  Lectures  on  Appendicitis. 

that  a  disproportionate  number  of  the  attacks  of  appendicitis 
among  my  cases  came  on  between  the  hours  of  one  and  five 
o'clock  in  the  morning. 

The  temperature  of  appendicitis  is  interesting  because  of  its 
lack  of  importance.  Though  failing  to  indicate  the  extent  of 
infection,  it  gives  a  clue,  I  think,  to  the  character  of  the  infection. 
Thus,  the  high  temperatures  in  appendicitis  more  often  occur  when 
infection  is  mixed,  or  when  caused  by  streptococci.  A  tempera- 
ture of  103°  F.,  or  more,  at  the  outset  of  an  attack  of  appendicitis 
seems  to  mean  that  the  toxines  of  mixed  bacteria  are  sending  the 
temperature  up.     When  streptococci  become  ascendant,  the  tem- 


FiG.  II. — Section  of  muscular  coat  of  appendix,  showing  infiltration  of  leucocytes  in 

lymph  spaces. 

perature  may  go  to  105°  F.,  but  as  soon  as  the  colon  bacilli  con- 
trol the  field,  the  temperature  of  the  patient  may  be  expected  to 
drop,  and  to  fluctuate  within  a  range  of  one  degree  on  either  side 
of  100°  F.,  Avhile  the  disease  is  in  progress,  and  no  matter  how 
widespread  the  infection.  The  temperature  in  appendicitis  is  not 
often  elevated  after  the  lapse  of  a  few  hours,  and  a  colon  bacillus 
temperature  may  be  normal  or  subnormal  from  the  outset,  and  so 


Appendicitis. 


23 


continue  while  the  most  disastrous  effects  are  being  produced  by 
the  bacteria  in  the  tissues.  While  the  toxines  of  the  colon  bacil- 
lus apparently  do  not  send  the  patient's  temperature  up,  they 
nevertheless  pull  the  vital  signs  apart  most  insidiously,  and  it  is 
not  uncommon  in  cases  of  appendicitis  with  pure  cultures  of  colon 
bacilli,  to  find  a  temperature  averaging  99°  F.,  and  the  pulse  rate 
averaging  120  beats  per  minute  for  several  days  in  succession. 
We  must  not  look  to  the  temperature  then  in  trying  to  judge  of 
the  severity  of  an  attack  of  appendicitis.  But  the  pulse  becomes 
important  when  it  indicates  the  degree  of  intoxication  of  the 
sympathetic    nervous     system.       Complete     destruction    of    the 


Fig.  12. — Longitudinal  section  of  vein  in  mesappendix,  showing  thrombus  surrounded 

by  leucocytes. 

walled-in  appendix,  however,  may  take  place  without  producing 
much  change  in  the  character  of  the  pulse,  so  that  neither  pulse 
nor  temperature  in  appendicitis  gives  an  indication  of  the  extent 
of  the  destruction  of  the  appendix  proper.  The  lymph  spaces  of 
the  lymphoid  coat,  together  with  the  lymphatic  vessels  of  the 
appendix  and  mesappendix,  are  often  completely  blocked  with 
exudates    and    infiltrates  a  few    hours  after  infection   has    com- 


24 


Lectures  on  Appendicitis. 


menced.  Blocking  of  the  lymphatic  spaces  interferes  quickly 
with  the  lymph  circulation.  Infective  lymphatitis  frequently  ex- 
tends from  the  lymph  channels  of  the  appendix  to  those  of  the 
colon  and  mesentery.  The  veins  of  the  appendix  are  variously 
thrombosed  by  the  infection,  and  the  process  may  go  on  to  ex- 
tensive mesenteric  thrombo-phlebitis,  pyle-phlebitis,  portal  embol- 
ism, and  abscess  of  the  liver.  Abscess  of  the  liver  from  septic 
appendix  emboli  may  be  looked  for  in  almost  any  stage  of  appen- 
dicitis. The  earliest  case  that  has  come  under  my  notice  occurred 
on  the  fifth  day.  There  is  no  doubt  that  hepatic  abscess  appears 
in  some  cases  of  appendicitis  that  are  too  mild  to  attract  the  at- 
tention of  the  physician  directly  to  their  original  character,  as  I 
have  found  thrombi  ready  to  become  emboli  in  the  mesappendices 
of  such  cases. 


Fig.  13. — Proliferating  endarteritis  of  solitary  artery  of  appendix. 

Arterial  complications  give  rise  to  some  of  the  most  striking 
phenomena  of  appendicitis.  When  the  solitary  terminal  artery 
of  the  appendix  becomes  the  seat  of  proliferating  endarteritis, 
round  sloughs  form  at  the  ends  of  the  arterial  twigs  that  are  first 
obliterated,  or  the  whole  appendix  sloughs  from  deficient  blood 


Appendicitis. 


25 


supply.  In  some  cases  in  which  endarteritis  causes  obstruction, 
but  not  occlusion,  slow  ulceration 
occurs  opposite  the  most  affected 
branches  of  the  artery.  The  com- 
plication of  proliferating  endarte- 
ritis I  first  described  in  September, 
1893,  but  had  previously  examined 
several  examples  of  it,  finding  that 
the  tunica  intima  had  undergone 
rapid  proliferation  as  the  result  of 
acute  infection.  The  solitary  ar- 
tery of  the  appendix  is  obstructed 
sometimes  in  accidental  disloca- 
tion of  the  appendix.  The  ex- 
pression, "  dislocation  of  the  ap- 
pendix," is  almost  an  unsafe  one 
to  use,  because  the  appendix 
may  occupy  such  a  variety 
of  positions  in  relation  to  the 
cecum  ;  but  when  any  one  appen- 
dix which  belongs  behind  the 
cecum  is  thrown  out  from  behind 
the  cecum  by  a  sudden  blow  or 
by  an  unusual  muscular  effort,  and 
when  it  cannot  return  to  a  position 
for  which  its  mesappendix  was 
adapted,  that  particular  appendix 
may  be  spoken  of  as  a  dislocated 
one,  and  it  may  remain  so  strongly 

twisted  upon  itself,  including  the      ; 

mesappendix,  that  arterial  and 
venous  circulation  is  interfered 
with.  This,  I  think,  is  the  origin  of  a  cer- 
tain proportion  of  cases  of  appendicitis. 
The  connective-tissue  planes  of  the  ap- 
pendix conduct  infection  to  neighboring 
loose  connective  tissues,  and  very  exten- 
sive sub-peritoneal  abscesses  may  form, 
sometimes  at  such  a  distance  from  the 
appendix  as  to  mislead  the  surgeon  be- 
cause of  their  simulating  peri-hepatitis  or  peri-nephritis,  or  psoas 


Fig.  14. — Two  round  sloughs. 


26 


Lccitircs  on  Appe7idicitis. 


abscess.  In  two  of  my  cases,  phlebitis  of  the  veins  of  the  left  leg 
occurred  as  a  result  of  infection  travelling  from  the  appendix 
across  the  pelvis  by  way  of  the  sub-peritoneal  connective  tissues. 
In  another  case,  an  abscess  formed  along  the  left  pelvic  brim. 

The  nerves  of  the  appendix  are 
acutely  inflamed  in  progressing  in- 
fection, but  the  most  interesting 
nerve   complications  occur  after  the 
attack  of  appendicitis  has  subsided. 
Nerve  filaments  caught  in  contract- 
ing scar  tissue  are  the  source  of  per- 
sistent discomfort  for  the  patient,  but 
the  principal  symptoms  appear  to  be 
due    to    chronic    sclerosis    following 
acute  neuritis.     The  interstitial  con- 
nective-tissue elements  of  the  nerves 
undergo    marked    hypertrophy.      In 
some  cases  in  which  the  appendix  has 
disappeared    Avith   the  exception    of 
a  fibrous  string  of    connective 
^^    tissue,    ill-defined     muscularis 
and  peritoneum,  the  sclerosed 
nerves  yet  keep  the  patient  more  or 
less  of  an  invalid,  because  they  ex- 
ert an  influence  which    inhibits  the 
peristaltic  movements  of  the  colon, 
and  predisposes  to  constipation,  in- 
testinal   fermentation,    and    general 
dyspeptic  symptoms.       I    supposed 
that   this    influence  was  due  to  old 
adhesions  until  I  found  that  patients 
in  whom  few  adhesions  existed  were 
relieved   from  their   discomfort  and 
rapidly  gained  in  health  and  strength 
Fig.  15.— Single  round  slough,    after    the    removal    of  sclerosed    ap- 
pendix remains. 
Peritonitis  is  the  most  important  complication  of  appendicitis, 
and  one  which  formerly  attracted  our  attention  so  closely  that 
the  appendix  Avas  often  overlooked.     The  simplest  form  of  peri- 
tonitis complicating  appendicitis  is  limited  to  the  peritoneum  of 
the  appendix  and  mesappendix.     The  irritating  products  of  bac- 


Appendicitis. 


27 


teria  at  work  within  cause  a  reddening  and 
roughening  of  the  serosa  of  the  appendix  and 
mesappendix.  The  latter  contracts  firmly,  re- 
maining contracted  and  fixed  by  adhesions  if 
the  inflammatory  process  is  severe  enough  to 
cause  the  formation  of  plastic  peritoneal  exudates 
on  the  layers  of  the  mesappendix.  When  the 
leucocytes  fail  to  limit  the  peritonitis  to  the  region 
of  the  appendix,  by  their  anti-toxine,  the  peri- 
toneum over  near-by  structures  throws  out  plastic 
exudate,  and  the  appendix  is  entirely  surrounded 
by  adhesions  which  wall  it  in.  This  is  a  very 
pretty  subterfuge  on  the  part  of  Nature,  and  it 
protects  the  patient  unless  bacteria  have  gained 
too  much  headway.  Nature  is  appreciative  of 
success,  however,  and  when  the  bacteria  have 
proven  themselves  to  be  very  enterprising,  she 
transfers  her  interests  from  the  patient  to  the  fine 
colony  of  bacteria  whose  claims  for  vested  inter- 
ests outweigh  those  of  the  patient.  In  such  a 
case  the  protecting  peritoneal  exudate  is  liquefied 
by  the  bacteria  which  escape  into  the  general 
peritoneal  cavity  in  large  quantities,  and  which 
excite  a  diffuse  peritonitis  if  the  patient  is  under 
the  influence  of  opium.  If  we  help  the  patient, 
however,  by  passing  hygroscopic  salts  through  the 
alimentary  tract,  and  allow  natural  events  to  fol- 
low, toxic  fluids  are  drawn  into  the  intestinal  canal 
by  osmosis,  and  active  phagocytosis  takes  place  so 
rapidly  in  the  broad  field  of  the  peritoneum  that 
the  patient  may  be  saved.  Our  intense  fear  of 
pus  in  the  peritoneal  cavity  is  unwarranted  by 
present  knowledge,  and  some  pus  in  some  peri- 
toneal cavities  is  certainly  harmless,  if  we  manage 
the  peritoneum  well.  Before  its  functions  were 
well  understood  the  peritoneum  was  often  mis- 
used, and  it  responded  in  kind,  so  that  we  feared 
peritonitis.  In  our  day  the  peritoneum  has  be- 
come the  surgeon's  best  friend,  and  with  its  aid 
the  most  extensive  abdominal  operations  are 
done    with    safety.       We    call    it    to    our    aid    in 


3, 


0\ 


Fig.  16.— Whole  appendix, 
gangrenous  and  sloughing. 


28 


Lectures  on  Appendicitis. 


walling  in  the  buried  stump  after  the  removal  of  the  appendix, 
and  we  direct  it  to  dispose  of  bacteria  and  toxines.  To-day, 
the  peritoneum  does  yeoman  service  for  or  against  the  patient, 
according  to  the  dictation  of  the  surgeon.  The  extent  of  in- 
fection in  a  case  of  peritonitis  with  appendicitis  bears  no  direct 
relation  to  the  extent  of  destruction  in  the  appendix  itself.  The 
most  violent  peritonitis  can  occur  in  cases  in  which  bacteria  have 
migrated  out  of  the  appendix  by  w-ay  of  the  blood-vessels,  lym- 
phatics or  loose  connective-tissue  planes,  not  going  through  the 
walls  of  the  appendix.  On  the  other  hand,  a  very  little  local 
peritonitis    may  suf^ce    to    wall   in   a   perforated   or  completely 


Fig.  17. — Gangrene  of  mesappendix, 

A.  Appendix  not  yet  dead. 

B.  Mesappendix. 


sloughing  appendix.  We  therefore  over-estimated  the  relative 
importance  of  perforation  of  the  appendix  formerly.  The  fallacy 
has  gone  abroad  that  the  appendix  is  usually  destroyed  in  cases 
in  which  abscesses  have  formed.  We  opened  such  abscesses  without 
doing  anything  further  in  former  years,  before  the  principles  in- 
volved were  clearly  in  mind,  and  have  subsequently  removed 
from  these  patients  appendices  which  had  suffered  comparatively 
little  damage.  There  are  certain  cases  in  which  it  is  wise  to  leave 
an  infected  appendix  at  the  bottom  of  an  abscess  cavity,  but  such 
appendices  cannot  be  left  on  the  theory  that  they  will  give  no 


Appendicitis. 


29 


further  trouble  after  the  patient  has  recovered.  In  one  of  my 
cases,  in  which  a  flood  of  intra-peritoneal  pus  was  discharged  by 
way  of  the  mouth  and  vagina  simultaneously,  entering  the  mouth 
after  perforation  of  the  lung,  the  patient  had  subsequent  attacks 
of  appendicitis,  and  the  appendix  on  being  finally 
removed  was  found  to  present  simply  two  scar- 
strictures  and  a  honeycombed  lymphoid  coat,  the 
outer  tube  of  the  appendix  being  unperforated. 
When  bacteria  have  liquefied  the  peritoneal 
plastic  exudate  about  a  walled-in  appendix,  the 
peritoneum  usually  protects  by  putting 
up  new  plastic  walls  farther  and  farther 
away,  so  that  enormous  walled-in  ab- 
scesses frequently  result.    Very  often 


Fig.  18. — Perforated  appendix.  Fig.  19. — Multiple  perforations  of  appendix. 


30  Lect2ircs  on  Appendicitis. 

the  plastic  exudate  becomes  liquefied  by  bacteria  at  several  points, 
leaving  firm  exudate  in  the  intervals,  and  we  then  have  multiple 
abscesses.  That  fact  forms  the  rational  basis  for  the  procedure 
of  separating  all  adhesions  in  some  operations  upon  acute  appen- 
dicitis cases  with  pus.  If  we  evacuate  one  large  abscess,  a  very 
small  undiscovered  abscess  may  prove  fatal  to  the  patient.  Intra- 
peritoneal abscess  cavities  sometimes  fail  to  evacuate  their  con- 
tents spontaneously,  or  to  prove  fatal  to  the  patient,  and  such 
collections  of  fluid  may  remain  encapsulated  for  many  years, 
making  the  patient  an  invalid,  and  subjecting  him  to  the  distress 
of  acute  exacerbations  of  inflammation  from  time  to  time.  If  in 
such  encapsulated  collections  the  bacteria  kill  themselves  and 
their  spores  with  toxines,  the  sterile  fluid  and  contained  debris 
may  undergo  absorption.  Abscess  fluids,  whether  formed  within 
the  peritoneal  cavity  or  in  the  sub-peritoneal  connective  tissues, 
if  neglected  by  the  surgeon,  may  open  externally  upon  the  abdo- 
men, or  they  may  perforate  the  ureter,  the  bladder,  the  bowel, 
the  iliac  vessels,  or  even  the  pleura  and  lung.  An  appendicitis 
patient  with  an  abscess  cavity  that  is  seeking  a  point  for  evacua- 
tion of  its  contents,  is  consequently  in  a  most  critically  dangerous 
position.     A  large,  intra-peritoneal  abscess  may  form  with  com- 


FlG.  20. — Appendix  kept  partially  alive  by  adhesion  circulation  after   destruction  of 

its  artery. 

paratively  little  pain,  but  intense  suffering  results  from  abscess 
formation  about  the  iliac  arteries,  because  the  strong  pulse  gives 
an  unceasing  succession  of  blows  to  the  sensitive  structures  that 
are  bound  to  the  spot  by  plastic  exudate. 

When  an  abscess  forms  about  the  large  nerves  of  the  pelvis,  a 
distressing  neuralgia  complicates  the  case.  Adhesion  bands  are 
extremely  common  after  recovery  from  acute  appendicitis.  The 
plastic  exudate  which  is  thrown  out  for  the  protection  of  the 
patient  may  undergo  nearly  complete  absorption  if  the  case  is 
one  of  short  duration,  and  in  other  cases  short,  firm  adhesions 


Appendicitis. 


;i 


remain  permanently,  but  cause  little  trouble.      In  a  less  ffjrtunate 
group  of  cases,  the  adhesions  are  pulled   out  into  Ioulj  bands  by 


'^*%s*-,; 


Fig.  21. — Interval  case.     Circulation  interfered  with  by  adhesions. 

the  action  of  the  moving  viscera.  A  complication  similar  to 
adhesion  bands  is  caused  by  the  omentum,  which  is  very  com- 
monly caught  in   adhesions  at    that   part   of    its    border    which 


Fig.  22. — Interval  case.     Three  pus  cavities  formed  by  scar  strictures. 

A.  Pus  cavity. 

B.  Scar  strictures  occluding  lumen  of  appendix. 

touches  the  appendix.  The  movements  of  the  viscera  then  roll 
the  free  mass  of  omentum  up  into  a  rope,  or  divide  it  into  fila- 
ments, which,  fixed  above  and  below,  set  a  trap  for  loops  of 
bowel.  Adhesion  bands  cause  volvulus  and  kinking  of  the  bowel. 
They  mechanically  inhibit  peristalsis  of  the  colon,  and  strangula- 
tion of  the  bowel  occurs  in  such  adhesion  bands  years  after  an 
attack  of  appendicitis  has  been  forgotten,  if  it  was  ever  recog- 
nized. The  most  frequent  complications  caused  by  intra-peri- 
toneal  adhesion  bands  are  not  the  dangerous  ones,  but  consist 
simply  in  chronic  constipation  from  mechanical  inhibition  of 
peristalsis,  or  in  occasional  attacks  of  distress  from  temporary 
incarceration  of  knuckles  of  bowel.  A  phlebitis  of  the  iliac  and 
femoral  veins  is  a  common  complication  of  infective  appendicitis, 
and  may  cause  death  in  a  case  which  is  otherwise  a  moderate  one. 
Acute  suppurative  nephritis  may  suddenly  appear  in  a  very  sim- 


32 


Lectures  on  Appendicitis. 


pie  case  of  appendicitis  by  infection  travelling  up  the  ureter.  I 
lost  one  such  patient,  a  student  who  came  into  the  office  smiling, 
with  his  books  under  his  arm,  and  saying  that  his  physician 
thought  he  had  appendicitis,  and  wished  to  have  me  see  the  case, 
I  found  an  appendix  somewhat  tender  and  firm  with  interstitial 
exudate,  but  the  patient  had  no  constitutional  symptoms  of  in- 
fection. I  asked  him  to  enter  the  hospital  the  next  day  and 
have  the  appendix  out.  When  I  saw  the  patient  on  the  follow- 
ing day,  he  was  in  a  hopeless  condition  from  acute  suppurative 
nephritis,  which  proved  fatal. 


Fig.  23. — Post-appendicitis  adhesion  band  from  cecum  snaring  a  loop  of  ileum. 

Septic  pleuritis  and  pneumonitis  suddenly  and  unexpectedly 
develop  in  any  stage  of  progress  of  infective  appendicitis.  Tuber- 
culosis and  neomata  of  the  appendix  are  not  often  complicated  by 
infective  appendicitis,  because  the  progress  of  these  diseases  is 
slow,  and  the  structures  of  the  appendix  have  ample  time  to  ad- 


Appendicitis.  33 

just  themselves  to  the  new  conditions,  just  as  they  do  in  hydrap- 
pendix  where  slowly  accumulated  mucus,  dammed  by  a  stricture 
and  sterile  from  suicide  of  its  bacteria,  gradually  forces  the  lym- 
phatics and  blood-vessels  to  become  hypertrophic  in  a  compensa- 
tory way.  Such  compensatory  hypertrophy  and  multiplication  of 
structures  is  impossible  under  ordinary  conditions  of  acute  infec- 
tion. Catarrhal  appendicitis  has  not  been  observed  by  me  as  yet, 
because  I  differentiate  infective  appendicitis  from  catarrhal  colitis 
with  involvement  of  the  appendix,  and  do  not  operate  in  the 
latter  cases,  nor  do  I  call  them  cases  of  appendicitis.  When  I 
operate  it  is  upon  cases  of  infective  appendicitis  in  various  stages 
of  progress,  and  the  responsibility  that  goes  with  the  making  of  a 
diagnosis  is  such  that  I  believe  it  to  be  morally  wrong  for  us  to 
make  the  diagnosis  of  catarrhal  appendicitis  at  the  bedside  before 
the  specimen  has  been  seen.  The  simplest  stage  of  infective  ap- 
pendicitis, and  one  which  is  perhaps  most  often  wrongly  called 
catarrhal  appendicitis,  causes  symptoms  when  exudate-compres- 
sion-anemia  and  toxic  destruction  of  cells  cause  a  small  portion  of 
the  inner  tube  of  the  appendix  to  disappear  by  ulceration,  or  by 
sloughing,  before  the  resistance  factors  are  in  control  of  the  tissues. 
When  infection  halts,  the  gap  left  in  the  tissues  of  the  inner  tube  is 
closed  by  granulation,  and  eventually  by  connective  tissue,  which 
slowly  contracts  and  narrows  or  closes  the  lumen  of  the  appendix. 
In  such  a  case  the  patient  may  be  free  from  symptoms  of  appendi- 
citis in  two  or  three  days,  but  the  progress  of  mild  infective  appendi- 
citis is  often  protracted,  and  marked  by  slow  erosion  of  mucosa  and 
lymphoid  tissue,  caused  by  pressure  of  interstitial  exudates  ;  by 
muscular  spasm  of  the  outer  tube,  by  obliterating  hyperplasia  of 
the  tunica  intima  of  small  arterial  branches,  by  plugging  of  lymph 
channels,  or  by  direct  toxic  destruction  of  cells.  Connective 
tissue  gradually  replaces  the  broken-down  inner  tube,  and  if  it  is 
■evenly  replaced  without  the  formation  of  stricture  nodes,  the  dis- 
ease may  eventually  disappear  without  causing  disaster  or  even 
very  marked  symptoms.  In  these  chronic  cases  of  infective  ap- 
pendicitis, all  structures  excepting  the  mucosa  frequently  become 
excessively  hypertrophic  during  the  period  of  infection,  but  finally 
nothing  remains  excepting  a  string  of  connective  tissue  surrounded 
by  ill-defined  remains  of  muscle  and  peritoneum,  and  containing 
sclerotic  nerves.  We  cannot  reasonably  expect  that  any  particu- 
lar case  of  appendicitis  will  end  in  this  way,  because  the  accidents 

of  acute  exacerbations  of  the  infection  too  often  bring  the  case 
3 


34 


Lectures  on  Appendicitis. 


to  a  more  abrupt  termination.  In  the  more  vicious  forms  of  acute 
infective  appendicitis,  all  structures  of  the  appendix  are  partly  or 
wholly  destroyed  quickly.  If  the  appendix  is  well  walled  in  with 
plastic  lymph,  the  sloughs  which  form  are  decomposed  by  sapro- 
phytes, and. the  stump  of  the  appendix  or  the  opening  in  the 
cecum  gradually  heals.     Rhexis  of  the  appendix,  a  condition  in 


Fig.  24. — Rhexis  of  middle  segment  of  appendix — A. 

which  the  capillary  vessels  allow  their  contents  to  escape  inter- 
stitially  into  all  the  structures  of  the  appendix,  dissecting  tissues 
apart,  and  distending  structures  with  blood,  indicates  a  savage 
type  of  infection,  but  one  which  occasionally  fails  to  give  symp- 
toms of  importance  until  the  condition  of  gangrene  supervenes. 
Appendicitis  occurs  principally  in  young  males.  The  fact  that 
women  do  not  suffer  from  this  disease  so  often  as  men  has  been 
well  established  by  post-mortem  examination  statistics,  and  is  not 
based  on  the  theory  that  in  women  diseases  of  the  ovaries  and  ovi- 
ducts are  more  often  mistaken  for  appendicitis,  because  such 
mistakes  in  diagnosis  are  easily  avoided.  There  are  three 
fairly  good  reasons  why  women  suffer  less  often  from  appendi- 
citis, viz. :  (i)  There  is  sometimes  collateral  circulation  by  way 
of  the  appendiculo-ovarian  ligament ;  (2)  women  expose  them- 
selves less  to  the  production  of  traumatic  infection  atria ;  and  (3) 
the  flaring  pelvis  in  women  is  not  so  likely  to  hold  a  displaced 
appendix  in  a  cramped  position.  About  twenty  per  cent,  of  the 
cases  of  appendicitis  occur  in  women.  It  is  most  common  in  both 
sexes  between  the  ages  of  ten  and  thirty-five.     But  it  may  occur 


Appendicitis.  3  5 

in  the  infant  at  the  breast,  or  in  the  old  man  in  his  dotage.  The 
very  young,  and  those  past  middle  life,  expose  themselves  less 
often  to  the  production  of  traumatic  infection  atria.  Another 
reason  why  the  disease  occurs  more  rarely  after  middle  age  is  be- 
cause the  appendix  undergoes  a  certain  involution  process,  which 
sometimes  leaves  it  bare  of  mucosa  and  lymphoid  tissue  in  old 
age. 

A  nomenclature  has  been  sought  for  the  description  of  various 
kinds  of  appendicitis,  but  apparently  there  is  only  one  kind  of 
appendicitis  which  produces  acute  symptoms, — infective,  exuda- 
tive appendicitis, — caused  by  bacterial  invasion  of  a  structure 
which  is  peculiarly  unfitted  to  resist  the  effects  of  such  an  inva- 
sion. The  various  phenomena  of  infective  appendicitis  should 
not  be  described  as  indicating  different  kinds  of  appendicitis,  but 
rather  as  marking  different  forms  of  one  kind  of  disease.  Thus 
we  may  speak  of  the  acute  or  chronic  form,  the  form  of  endo- 
appendicitis,  or  of  perforation,  or  of  hydrappendix,  and  so  on  in- 
definitely ;  but  as  endo-appendicitis  may  be  present  on  Monday 
and  perforating  appendicitis  may  appear  on  Wednesday  in  the 
same  case  without  our  being  able  to  state  what  Friday  appen- 
dicitis may  be  like,  we  might  classify  these  cases  as  "  Monday," 
"  Wednesday,"  and  "  Friday  "  appendicitis.  The  diagnosis  in 
each  case  would  be  made  afterward.  We  cannot  know  that  any 
attack  of  infective  appendicitis  will  stop  at  any  one  form  short  of 
complete  destruction,  because  the  power  of  the  principal  resist- 
ance factor  in  any  one  case  is  absolutely  unknown.  By  "  resist- 
ance factor  "  I  mean  so-called  phagocytosis.  We  can  place  a  case 
in  a  certain  sort  of  classification  after  we  have  seen  the  specimen^ 
but  such  a  post-diagnosis  is  not  more  fair  than  a  game  of  whist 
after  an  opponent's  hand  has  been  seen.  If  we  classify  cases  as 
fulminating  cases,  or  as  cases  with  abscess,  we  are  classifying  them 
from  the  symptoms  of  complications  without  reference  to  the 
actual  condition  of  the  appendix,  or  the  form  of  the  appendicitis 
proper. 

There  are  no  groups  of  symptoms  which  will  allow  us  to  make 
a  rational  prognosis  as  to  the  eventual  outcome,  or  the  prospec- 
tive complications  in  any  progressing  case  of  appendicitis,  and 
we  must  abandon  the  hope  of  having  any  such  classification  of 
symptoms  for  a  guide  in  the  future.  Attempts  will  be  made  from 
time  to  time  to  classify  symptoms  for  prognosis  from  small  groups 
of  cases,  but  they  will  fail  because  of  the  nature  of   the  disease. 


36  Lectures  on-  Appcndiciiis. 

I  speak,  then,  unequivocally,  knowing  that  some  patients  are  to 
die  and  others  are  to  suffer  unnecessarily  because  their  advasers 
will  believe  themselves  to  be  upon  a  prognostic  track.  There  is 
but  one  rule  to  be  followed,  and  that  is  to  isolate  an  infected 
appendix  as.  promptly  as  we  would  isolate  a  case  of  diphtheria 
and  for  practically  the  same  reasons,  viz. :  the  infected  appendix 
will  probably  infect  other  structures,  and  the  infected  throat  is 
likely  to  infect  other  throats.  An  infected  appendix  is  isolated 
when  it  is  out  of  the  patient.  All  cases  of  appendicitis  that  are 
otherwise  wathin  surgical  limitations,  and  that  are  within  reach  of 
competent  surgical  services,  are  cases  for  prompt  isolation  of  the 
appendix.  Various  periods  of  waiting  have  been  tried  with  the 
effect  of  proving  that  the  question  is  wedge-shaped,  with  the 
greatest  number  of  deaths  at  the  broad  waiting  end,  and  the 
smallest  number  of  deaths  at  the  point  of  isolating  an  infected 
appendix  while  infection  is  limited  to  the  confines  of  the  appendix. 
We  are  held  to  our  rule  by  two  cardinal  principles,  viz. :  (i)  Every 
hour  of  progress  of  any  acute  attack  of  appendicitis  means  in- 
creased damage  to  viscera ;  and  (2)  with  no  infected  appendix  the 
patient  would  have  no  complications  of  appendicitis,  and  there- 
fore the  patient  would  have  no  complications  of  appendicitis  if  we 
leave  him  with  no  infected  appendix.  It  then  becomes  a  matter 
of  interest  to  note  the  comparison  between  the  death-rate  of 
medical  and  surgical  treatment  of  appendicitis.  Statistics  from  a 
large  number  of  observers  give  an  average  death-rate  in  the  prin- 
cipal attack  of  appendicitis  of  about  fifteen  per  cent,  under  medi- 
cal treatment,  and  I  assume  from  experience,  without  being  able 
to  obtain  available  data  for  reference,  that  nearly  ten  per  cent, 
more  die  from  the  numerous  chronic  complications  resulting  from 
previous  acute  attacks.  According  to  Bull's  statistics,  from  a 
large  number  of  selected  operators,  the  surgical  death-rate  of 
appendicitis  is  not  far  from  two  per  cent,  in  cases  operated  upon 
at  a  time  when  infection  is  limited  to  the  confines  of  the  appen- 
dix. Bull's  statistics,  however,  include  only  "  interval  cases" — 
cases  which  were  already  of  the  complicated  class.  I  believe  that 
a  surgical  death-rate  of  two  per  cent,  is  illegitimate  in  cases  oper- 
ated upon  in  the  first  attack  before  infection  has  extended  beyond 
the  confines  of  the  appendix.  If  the  surgical  death-rate  were 
fourteen  per  cent,  and  the  medical  death-rate  fifteen  per  cent. 
our  duty  Avould  still  be  clear.  We  have  learned  that  the  peri- 
toneum is  not  to  be  feared  by  the  surgeon  in  such  cases,  and  now 


Appendicitis.  t^j 

that  we  know  the  possible  dangers  of  ligating  the  appendix  h'ke 
an  artery,  there  are  no  further  dangers  in  sight  excepting  from 
an  imperfect  aseptic  technique,  a  responsibihty  which  rests  with 
the  individual  surgeon,  and  from  ordinary  causes  which  have  no 
direct  connection  with  the  appendicitis.  From  experience  I  judge 
that  we  must  place  the  surgical  standard  at  less  than  one  per 
cent,  mortality  rate  in  cases  of  appendicitis  operated  upon  by 
skilled  operators  at  the  proper  time  for  removal  of  infected 
appendices. 

The  surgical  treatment  of  appendicitis  has  made  three  distinct 
steps  in  progress  within  the  past  decade.  Ten  years  ago  we 
simply  opened  the  abscesses  of  appendicitis  when  they  were 
strongly  in  evidence.  The  first  planned  operations  for  the  removal 
of  infected  appendices  were  done  about  the  time  when  Dr.  Fitz, 
of  Boston,  gave  a  great  impetus  to  the  investigation  of  the  subject 
in  his  classical  paper  in  the  American  yoiirnal  of  the  Medical 
Sciences  in  1886.  Intense  interest  in  the  subject  w^as  soon  aroused, 
and  surgeons  generally  began  to  search  for  infected  appendices, 
but  at  such  a  late  stage  in  the  progress  of  the  disease  that  statis- 
tics at  first  showed  little  if  any  advantage  in  favor  of  surgical 
treatment.  The  reason  for  that  was  because  infection  at  the  time 
chosen  for  operation  was  beyond  the  reach  of  resources  of  the 
surgery  of  that  day.  Then  came  the  period  of  operating  in  the 
interval  between  attacks,  or  in  the  early  stages  of  the  first  attack, 
and  statistics  at  once  showed  the  very  great  advantages  of  this 
treatment. 

There  remained  then  only  the  necessity  for  perfecting  the 
operation  in  such  a  way  as  to  avoid  the  occurrence  of  post-opera- 
tive ventral  hernias  and  of  unsightly  scars,  and  this  has  now  been 
done.  Medical  treatment,  which  cannot  reach  the  bacteria  that 
are  invading  the  tissues  in  the  appendix,  will  nevertheless  give 
very  decided  comfort  in  many  cases  in  which  surgical  services  are 
not  obtainable.  Opium  will  cover  up  distressing  symptoms,  and 
allay  the  feeling  of  unrest  which  is  very  marked  in  appendicitis. 
Hot  fomentations  over  the  inguinal  region  will  relax  the  exhaust- 
ing spasm  of  the  abdominal  muscles,  and  may  sometimes  relax 
the  outer  tube  of  the  appendix  temporarily,  but  the  tonic  spasm 
of  the  muscular  tube  of  the  appendix  is  caused  by  direct  toxic 
irritation,  whereas  the  tonic  spasm  of  the  abdominal  muscles  is 
sympathetic,  and  due  to  a  reflex  from  the  appendix  region.  The 
orthopedists  are  the  only  members  of  our  profession  who,  as  a 


38  Lectures  oil  Appendicitis. 

class,  are  able  to  appreciate  the  exhausting  effect  and  the  disas- 
trous influence  of  long-continued  muscular  spasm.  When  hot 
fomentations  fail  to  relax  the  muscles  of  the  anterior  walls  of  the 
abdomen  completely,  we  may  be  quite  sure  that  muscular  spasm 
of  the  outer  tube  of  the  appendix  is  persisting  down  below,  unless 
that  outer  tube  is  destroyed  or  paralyzed  by  interstitial  exudates. 
Olive  oil  or  saline  cathartics  passed  through  the  alimentary  tract 
will  remove  fermenting  intestinal  contents,  and  decidedly  lessen 
the  so-called  auto-intoxication  which  is  an  element  of  much 
importance  in  these  cases.  Personally,  I  should  prefer  the  saline 
cathartics  for  the  purpose,  but  the  Homeopathists  have  used  olive 
oil  with  success  for  a  great  many  years,  and  we  may  rest  assured 
that  its  popularity  with  them  is  based  upon  observations  of  its 
usefulness.  By  usefulness  I  mean  the  obtaining  of  comfort  for 
the  patient.  His  chances  for  recovery  are  not  much  improved  by 
any  treatment  which  fails  to  remove  the  nest  of  infection,  and 
that  nest  is  out  of  the  road  of  medical  resources  in  appendicitis. 
So  many  patients  will  recover  from  one  or  more  attacks  without 
any  treatment  of  any  sort  that  Ave  are  apt  to  be  misled  as  to  the 
value  of  medical  treatment  excepting  as  to  the  comfort  which  it 
gives  a  distressed  patient. 

Appendicitis  patients  who  are  in  a  position  to  receive  surgical 
treatment  should  have  very  little  preparatory  medical  treatment. 
Opium  is  to  be  particularly  avoided,  especially  if  the  case  is  compli- 
cated by  peritonitis.  We  need  to  have  the  peritoneum  active  if  it 
is  to  serve  the  surgeon  well.  With  an  active  peritoneum  we  may 
open  the  abdomen  and  remove  the  tubular  tonsil  almost  as  safely 
as  we  open  the  mouth  and  remove  the  flat  tonsil,  provided  that 
the  operator  is  expert. 

Our  recognition  of  the  safety  of  such  work  under  the  principles 
of  new  surgery  would  tempt  us  to  remove  the  normal  appendix 
when  it  appears  in  the  field  of  our  other  abdominal  work.  To 
this  I  am  opposed  on  the  principle  that  the  death-rate  of  no 
surgical  operation  can  be  reduced  absolutely  to  zero,  and  the 
surgeon  who  would  protect  his  patient  must  not  remove  an  appen- 
dix until  there  is  infection,  and  consequent  occasion  for  removing 
it.  I  refuse  to  remove  uninfected  appendices,  and  can  find  at  the 
same  time  no  rational  excuse  for  failing  to  promptly  remove 
infected  appendices.  The  cause  of  prompt  operative  treatment 
for  appendicitis  has  had  to  labor  against  the  prejudice  aroused  by 
unnecessary  ovarian  surgery,  just  as  diphtheria  anti-toxine  to-day 


Appendicitis.  39 

has  to  labor  against  the  reaction  which  followed  the  trial  of  Koch's 
lymph.  The  operative  treatment  of  inflamed  ovaries  and  tubes 
had  a  pendulum  movement — too  many  operations  were  done 
because  the  reasons  for  operating  were  not  always  founded  on  a 
sufficiently  rational  basis.  Then  came  a  reaction,  and  to-day,  not 
enough  operations  are  done  in  some  localities.  Eventually  the 
equilibrium  will  be  found.  The  treatment  of  infected  appendices 
has  never  had  any  pendulum  simile,  but  rather  the  simile  of  a  door 
which  has  gradually  closed  upon  the  question  of  immediate  opera- 
tion, leaving  it  no  longer  an  open  one.  An  inflamed  ovary 
seldom  threatens  life  unless  it  is  the  seat  of  a  dangerous  neoma 
or  abscess ;  it  usually  responds  to  palliative  treatment,  and  may 
be  a  very  useful  organ.  An  appendix,  on  the  other  hand,  is  never 
a  useful  organ,  and  it  always  threatens  life  when  infected.  I 
frequently  spend  half  an  hour  in  the  attempt  to  save  a  damaged 
ovary,  separating  adhesions,  freeing  agglutinated  fimbriae,  and 
opening  a  closed  oviduct,  instead  of  removing  the  mass,  which  at 
first  looks  so  unpromising.  With  the  damaged  appendix  I  spend 
only  time  enough  for  its  removal.  Sometimes  when  engaged  in 
other  abdominal  work  I  find  phosphatic  or  fecal  concretions  in 
appendices,  and  liberate  them  by  pushing  them  through  into  the 
cecum,  not  disturbing  the  appendix  if  it  shows  no  evidence  of 
infection.  In  some  cases  so-called  ovarian  neuralgia  could  have 
been  relieved  if  the  surgeon,  on  finding  a  normal  ovary,  had  turned 
to  the  appendix  and  liberated  a  concretion.  It  is  rather  unsafe  to 
leave  an  appendix  which  has  contained  a  concretion,  unless  the 
surgeon  is  familiar  with  the  appearance  of  normal  appendices,  and 
it  is  only  within  the  past  year  that  I  have  dared  to  do  it.  There  is 
one  position  in  which  the  surgeon  may  hesitate  about  operating 
when  he  finds  a  far  advanced  case  of  appendicitis  at  his  first  visit, 
and  that  is  in  a  town  where  the  people  are  not  likely  to  distinguish 
between  Xht  post  hoc  and  XhQ  propter  hoc,  if  the  patient  dies  after 
the  operation,  and  not  because  of  the  operation.  The  surgeon 
knows  if  he  waits  for  the  bacteria  to  kill  themselves  by  their 
toxines,  or  to  be  killed  by  the  anti-toxines,  he  can  remove  the 
appendix  with  safety  as  an  "  interval  case."  He  also  knows  that 
the  patient  may  die  before  the  bacteria  cease  work  in  that  particu- 
lar case.  If  he  operates,  and  the  patient  dies  because  bacteria 
were  in  advance  of  surgical  resources,  all  operating  for  appen- 
dicitis may  be  stopped  in  that  town,  and  lives  may  be  lost,  and 
much  unnecessary  suffering  will  ensue  because  the  people  will 


40  Lectures  oii  Appendieiiis. 

fail  to  avail  themselves  of  proper  resources  at  a  proper  time. 
Consequently,  as  a  matter  of  policy,  the  surgeon  may  find  it  right 
to  adapt  himself  to  his  surroundings,  and  to  sacrifice  the  indi- 
vidual patient  by  refusing  to  give  him  help, — in  the  interest  of  the 
public.  More  lives  will  really  be  saved  in  such  a  town  if  in  such 
a  case  we  refuse  to  give  a  father  a  chance  to  live  for  his 
family,  or  refuse  to  try  to  help  a  son  who  is  the  sole  support  of 
aged  parents.  This  picture  is  by  no  means  a  fanciful  one,  as  we 
all  know  very  well.  Personally,  I  have  never  been  able  to  refuse 
to  help  the  individual,  and  other  patients  have  been  lost  from 
neglect  because  a  far  advanced  case  of  appendicitis  died  in 
spite  of  all  the  resources  which  could  be  applied.  No  such 
opprobrium  follows  the  death  of  an  appendicitis  patient 
under  medical  treatment.  The  progress  which  has  been 
made  in  the  treatment  of  appendicitis  has  been  based 
on  accurate  information  relating  to  the  problems  that  are 
involved,  just  as  we  have  made  recent  progress  in  many  other 
lines.  Not  many  years  ago,  when  a  woman  came  into  the  office 
complaining  of  sick-headache,  or  nervous  dyspepsia,  we  thought 
first  of  medical  treatment,  and  such  medical  treatment  was  usu- 
ally unsatisfactory  because  we  obtained  temporary  relief  only 
from  the  treatment  of  symptoms.  To-day,  in  making  a  diagnosis 
by  exclusion  in  such  a  case,  we  are  called  upon  to  eliminate  the 
possibilities  of  irritation  from  errors  of  refraction  or  inflamed  rec- 
tal papillae,  or  a  uterus  out  of  position,  or  septic  oviducts,  or  a 
loose  kidney,  or  carious  teeth,  or  hypertrophies  of  the  turbinated 
bones ;  and  the  proportion  of  such  cases  that  are  found  to  be 
essentially  surgical  is  very  large.  The  insane  asylums  are  now 
robbed  of  many  of  their  victims  by  our  present  knowledge  of  the 
accurate  methods  of  giving  relief — a  knowledge  which  makes  it 
easy  for  the  patient  and  difficult  for  the  physician,  in  contra-dis- 
tinction  to  the  not  very  old  plan  which  was  easy  for  the  physician, 
and  hard  for  the  patient.  Our  advances  in  the  field  of  appendi- 
citis, however,  now  make  treatment  easy  for  both  physician  and 
patient.  Ten  years  ago  most  of  our  appendicitis  cases  were 
treated  under  the  aliases  of  acute  indigestion,  bilious  colic,  mala- 
rial fever,  la  grippe,  peritonitis,  entero-colitis,  cecitis,  neuralgia  of 
the  bowel,  intussusception,  volvulus,  intestinal  obstruction,  typhli- 
tis, perityphlitis,  typhoid  fever,  salpingitis,  ovaritis,  gall-stones  or 
gravel ;  while  some  of  the  abscess  complications  caused  the  cases 
to  be  classed  as  psoas  abscess,  coxitis,  abscess  of  the  abdominal 


Appendicitis.  4 1 

wall,  peri-hepatitis  or  peri-nephritis.  Appendicitis  is  of  such 
common  occurrence  that  we  have  all  lost  friends  and  acquaint- 
ances from  that  disease,  and  such  multitudinous  forms  of  abdom- 
inal disease  are  simulated  by  appendicitis  that  we  must  press  with 
our  fingers  at  "■  McBurney's  point  "  in  almost  any  case  of  acute 
abdominal  inflammation  of  sudden  onset  as  regularly  as  we  would 
look  at  the  tongue.  I  have  seen  appendicitis  overlooked  on  post- 
mortem examination  in  former  years,  because  the  appendix  hap- 
pened to  be  buried  in  adhesions,  and  because  it  was  only  a  little 
thing  anyway  ! 

The  symptoms  of  appendicitis  do  not  indicate  the  condition  of 
the  appendix  more  closely  than  they  do  the  condition  of  the  in- 
fected wisdom  tooth  in  which  a  very  small  carious  point  of  infec- 
tion may  excite  an  intolerable  neuralgia,  or  it  may  be  the  cause 
of  suppurative  alveolar  disease,  pyemia,  septic  meningitis  or 
abscess  of  the  neck.  Another  wisdom  tooth  may  become  entirely 
carious  without  giving  any  symptoms  beyond  an  occasional  tooth- 
ache. We  may  find  a  completely  gangrenous  appendix  in  a  case 
in  which  the  patient  is  resting  quietly  in  bed  with  normal  tem- 
perature, pulse,  and  respiration.  The  reason  why  the  appendix  is 
free  from  tenderness  is  because  it  is  dead,  nerves  and  all.  The 
temperature  and  pulse  are  normal  because  toxines  are  not  escap- 
ing into  the  general  circulation.  The  face  of  such  a  patient, 
however,  usually  looks  "  wrong  "  to  the  members  of  his  family. 
In  another  case  with  trifling  ulceration  of  a  part  of  the  inner  tube 
of  the  appendix  we  may  find  the  patient  throwing  himself  out  of 
bed  on  the  floor,  rolling  in  agony,  and  striking  himself  upon  the 
head  with  any  near  object  in  an  insanity  of  pain  from  irregular 
spasm  of  the  muscular  coats  of  the  intestine,  otherwise  known  as 
colic.  His  temperature  may  be  103°  F.,  and  his  pulse  rapid. 
Such  extreme  cases  as  the  above  two  are  seen  by  all  of  us  who 
are  engaged  much  in  abdominal  work.  The  presence  or  absence 
of  an  inguinal  tumor  is  a  matter  which  must  not  be  taken  into 
consideration  in  estimating  the  value  of  the  testimony  of  symp- 
toms, because  an  acute  general  peritonitis  may  appear  in  a  case 
of  appendicitis  in  which  the  appendix  is  not  perforated,  and  not 
surrounded  by  plastic  lymph  ;  and  a  perforated  or  dead  appendix 
may  be  walled-in  by  plastic  lymph  which  is  barely  sufUcient  to 
close  the  opening  or  surround  the  slough.  In  the  latter  case  there  is 
danger  in  an  examination  for  tumor,  unless  the  surgeon  is  prepared 
for  immediate  operation  when  he  has  accidentally  separated  the 


42  Lcctiti'cs  on  Appendicitis. 

frail  adhesions  in  making  an  examination.  On  the  other  hand,  a 
large  mass  of  plastic  exudate  may  form  about  an  appendix  which 
is  whole,  or  perforated,  or  sloughing  in  its  entirety.  For  these 
reasons  the  presence  or  absence  of  an  inguinal  tumor  is  not  impor- 
tant as  giving  a  clue  to  the  condition  of  the  appendix  itself.  The 
groups  of  symptoms  which  belong  to  the  various  forms  or  com- 
plications of  appendicitis  are  so  multitudinous  as  to  be  extremely 
confusing  to  one  who  attempts  to  study  the  subject  from  the 
elaborate  descriptions  of  authors,  unless  he  has  had  considerable 
practical  experience  ;  and  yet  the  disease  is  diagnosticated  as 
readily  as  a  broken  leg  by  any  one  who  has  accustomed  himself 
to  looking  for  it.  The  correctness  of  such  diagnoses  are  verified 
by  operation. 

In  most  cases  of  appendicitis,  the  surgeon  is  guided  well  by 
certain  symptoms  which  are  of  pretty  regular  occurrence,  and  in 
order  to  give  a  clear  view  I  will  adopt  the  plan  of  describing  one 
typical  case  only. 

TYPICAL    CASE FIRST    DAY. 

Subjective  Symptoms . 

{a)  General  abdominal  pain  of  sudden  onset. 
[l))  Waves  of  colic. 

[c)  Nausea  and  vomiting. 

(d)  Tenderness  on  finger-point  pressure  at  McBurney's  point. 

Objective  Signs  on  Palpation  aiid  Inspection. 

(<?)  Abdominal  muscles  firmly  contracted  and  resisting  pressure. 

(/)  Appendix  feels  harder  than  the  cecum. 

(^)  Fulgurant  spasm  of  the  external  oblique  muscles  near  their 
costal  attachments  when  the  region  of  the  appendix  is  sharply  tapped 
with  the  finger. 

Testi7?iony  of  Little  Value. 

Pulse,  temperature,  respiration,  condition  of  the  bowels  and  bladder. 

A  nalysis  of  Symptoms. 

General  Abdovii7ial  Pain  is  due  to  the  reflection  of  irritation  along  the 
widespread  branches  of  the  superior  mesenteric  plexus,  suddenly  ap- 
pearing when  toxic  irritation  of  the  muscular  tube  of  the  appendix  has 
caused  it  to  contract  firmly  upon  its  contents. 

Colic  is  sympathetic  spasm  of  the  muscular  coats  of  the  bowel  due 
to  over-stimulation  of  Auerbach's  plexus,  but  such  spasm  of  the  small 


Appendicitis.  43 

intestine  and  colon  occurs  at  intervals,  instead  of  persisting,  as  it 
usually  does  at  the  centre  of  infection  in  the  appendix. 

Nausea  ajid  VojJiiting  mean  reversed  peristalsis  of  the  stomach,  caused 
by  toxic  irritation  of  the  sympathetic  nerves  at  the  appendix.  If  the 
vomiting  is  bilious  in  character,  it  shows  that  the  duodenum  is  also  re- 
versed, and  is  filling  the  stomach  with  bile.  Tenderness  on  finger  pres- 
sure at  McBurney's  point  is  due  to  inflammation  of  various  structures 
of  the  appendix  lying  beneath.  McBurney's  point  is  situated  about 
two  inches  from  the  anterior  superior  spine  of  the  ilium  on  a  line  drawn 
from  that  spine  to  the  navel.  The  appendix  sometimes  occupies  vari- 
ous positions  in  the  abdominal  cavity,  but  we  almost  invariably  find 
at  least  the  proximal  end  of  the  appendix  at  the  normal  site. 

The  tonic  contraction  of  the  muscles  of  the  anterior  abdominal  wall 
is  a  reflex  phenomenon,  and  one  which  we  read  as  meaning  that  the 
inflamed  appendix  is  to  be  protected  against  traumatism.  It  has  the 
same  significance  in  appendicitis  that  tonic  contraction  of  the  muscles 
of  the  thigh  has  in  coxitis.  It  is  interesting  to  note  that  the  abdominal 
"muscles  protect  an  inflamed  appendix  regularly,  but  that  they  usually 
fail  to  take  interest  in  an  inflamed  ovary  and  tube  situated  a  couple  of 
inches  away  and  remain  normally  relaxed.  This  point  is  one  of  import- 
ance in  some  cases  in  which  a  diagnosis  between  salpingitis  and  inflam- 
mation of  the  appendix  lying  in  the  pelvis  becomes  difficult. 

Hardness  of  the  appendix  is  due  to  interstitial  exudate,  and  palpa- 
tion easily  reveals  this  condition  in  the  "interval  cases"  of  appendicitis 
after  the  period  of  acute  infection  has  passed.  In  the  primary  stage  of 
acute  infection,  the  firm  contraction  of  the  abdominal  muscles  often 
makes  palpation  of  the  appendix  difficult  unless  the  patient  is  anesthe- 
tized, and  in  the  stage  of  recent  perforation  or  gangrene  of  the  appendix, 
it  is  dangerous  to  palpate.  Excepting  in  the  acute  stages  of  inflam- 
mation, palpation  of  the  appendix  is  easily  done,  as  soon  as  one  has 
taken  pains  to  become  a  little  expert  at  it.  Dr.  Edebohls's  plan  of  pal- 
pating the  appendix  is  as  follows  :  The  patient  lies  upon  his  back  with 
the  legs  comfortably  flexed.  "  The  examiner  standing  at  the  patient's 
right  begins  the  search  for  the  appendix  by  applying  two,  three,  or  four 
fingers  of  his  right  hand,  palmar  surface  downward,  almost  flatly  upon 
the  abdomen,  at  or  near  the  umbilicus  ;  while  now  he  draws  the  ex- 
amining finger  over  the  abdomen  in  a  straight  line  from  the  umbilicus 
to  the  anterior  superior  spine  of  the  right  ilium,  he  notes  successively 
the  character  of  the  various  structures  as  they  come  beneath  and  es- 
cape from  the  fingers  passing  over  them.  In  doing  this,  pressure 
exerted  must  be  deep  enough  to  recognize  distinctly,  along  the  whole 
route  traversed  by  the  examining  fingers,  the  resistant  surface  of  the 
posterior  abdominal  wall  and  of  the  pelvic  brim.      Cnly  in  this  way 


44  Lectures  on  Appe7idicitis. 

can  we  positively  feel  the  normal  or  the  slightly  enlarged  appendix. 
Pressure  short  of  this  must  necessarily  fail." 

Dr.  Edebohls's  method  of  palpating  is  very  satisfactory,  but  I  have 
lately  found  that  for  myself  an  easy  way  is  to  stand  on  the  patient's, 
right,  using  three  right-hand  fingers  to  feel  with,  and  three  left-hand 
fingers  placed  upon  these  to  press  with.  The  fingers  that  are  to 
do  the  feeling  are  pressed  by  means  of  the  three  others  down  under 
the  border  of  the  right  rectus  abdominis  muscle  at  the  level  of  the 
navel,  and  slowly  drawn  tovvard  the  examiner.  My  sole  landmark,  the 
ascending  colon,  is  then  felt  to  slip  out  from  under  the  fingers,  and  by 
repeating  the  process  toward  the  cecum,  we  soon  come  to  the  end  of  the 
cecum,  and  there  begin  to  hunt  for  the  appendix  by  rolling  the  cecum 
to  one  side  or  the  other  of  the  finger  tips.  The  proximal  end  of  the 
appendix  is  found  near  the  distal  extremity  of  the  cecum,  and  we  then 
follow  the  rest  of  the  appendix  in  any  direction.  The  proportion  of 
appendices  that  cannot  be  palpated  will  become  smaller  and  smaller  as 
the  finger  tips  become  educated.  The  point  about  using  no  muscular 
effort  in  the  hand  that  is  to  be  used  for  feeling  is  as  important  in  pal- 
pating appendices  as  it  is  in  palpating  ovaries  and  tubes.  The  very- 
delicate  sense  of  touch  is  preserved  if  the  left  hand  is  used  for  pushing 
upon  the  examining  hand.  The  only  structures  that  need  to  be  differ- 
entiated from  the  appendix  in  palpating  are,  the  iliac  artery,  the  epiploic 
appendages,  and  subperitoneal  lymph  glands.  Pulsation  distinguishes, 
the  iliac  artery  ;  an  epiploic  appendage  is  usually  much  shorter  thaa 
the  cecal  appendage,  but  it  is  often  necessary  to  roll  an  epiploic  append- 
age about  under  the  fingers  several  times  in  succession  in  order  tO' 
accurately  get  its  proportions.  Subperitoneal  lymph  glands  feel  pre- 
cisely like  the  tip  of  a  normal  appendix  when  they  are  swollen,  but  they- 
are  not  freely  movable,  and  are  short. 

Fulgurant  spasm  of  the  extei'-nal  oblique  muscles  I  so  name  because 
of  the  quick  tremulous  flashes  of  contraction  which  are  easily  observed 
near  the'costal  attachments  of  these  muscles  when  the  region  over  the 
appendix  is  tapped  quickly  with  the  finger  if  a  patient  is  not  too 
fleshy.  It  is  a  reflex  spasm  which  indicates  extraordinary  attempts  at 
protection  of  the  abdominal  contents  by  a  set  of  muscles  which  are 
already  protecting  up  to  a  last  degree  consistent  with  the  retention  of 
their  power. 

The  reason  why  the  pulse,  temperature,  and  respiration  give  no  testi- 
mony of  particular  value  at  the  outset  of  the  attack  of  appendicitis  is 
because  different  patients  respond  so  differently  to  the  first  impress  of 
toxines  on  the  great  sympathetic  nervous  system,  and  because  in  ap- 
pendicitis the  character  of  the  toxines  changes  rapidly  as  different  bac- 
teria become  ascendant.     The  effect  is  as  varying  in  character  as  is  the 


Appendicitis.  45 

effect  of  the  toxine  of  saccharomyces  (alcohol)  upon  the  same  patient 
if  used  in  different  media  such  as  champagne,  beer,  and  absinthe. 

Co7istipatio7i  and  dial  rhea  are  of  little  value  as  first  signs,  because 
toxines  may  inhibit  peristalsis  and  may  stop  the  production  of  mucus  by 
paralyzing  portions  of  Meissner's  plexus.  If  the  infected  appendix  lies 
near  to  the  hypogastric  sympathetic  plexus  and  excites  its  branches, 
the  patient  may  be  compelled  to  empty  his  bladder  every  half  hour  ;  if 
the  sacral  plexus  is  first  involved,  the  patient  may  b.ave  spastic  dysuria  ; 
if  neither  plexus  is  disturbed,  the  bladder  will  not  be  disturbed,  and 
consequently  the  character  of  the  disturbance  of  the  bladder  is  of  little 
consequence  except  as  showing  where  some  part  of  the  appendix  prob- 
ably lies. 

TYPICAL    CASE T-HIRD    DAY. 

Subjective  Symptoms. 

(a)   Pain,  localized  in  the  right  inguinal  region. 

{^)  Anorexia. 

{c)  Tenderness  on  pressure  anywhere  in  the  right  inguinal  region. 

(^)  Constipation. 

Objective  Signs. 

{e)  Face  anxious. 

{g)  Abdominal  muscles  contracted  and  resisting. 

{Ji)  Peritoneal  lymph  adhesions  obscure  the  outlines  of  the  appendix 
on  palpation. 

Symptoms  of  little  value  are  given  by  the  temperature  and  pulse. 
JPaiii  is  localized  i?i  the  right  inguinal  region,  because  reflex  pains  in 
•other  parts  of  the  abdominal  cavity  are  not  likely  to  continue  for  more 
than  one  or  two  days  in  appendicitis.  Tenderness  on  pressure  any- 
where in  the  right  inguinal  region  is  due  to  inflammation  of  structures 
round  the  appendix.  Constipation  is  probably  symptomatic  of  Na- 
ture's attempt  to  keep  the  vicinity  of  the  appendix  undisturbed,  and 
.adhesions  of  the  cecum  aid  very  materially  in  inhibiting  the  peristal- 
sis at  that  point.  So  marked  is  the  constipation  in  many  cases  that  it 
amounts  practically  to  bowel  obstruction.  The  paiienfs  face  is  anxious, 
presumably  because  of  toxic  paralysis  of  motor  nerves  supplying  mus- 
cles of  the  face.  A  much  more  destructive  process  two  inches  from  the 
appendix,  in  an  ovary  in  which  other  species  of  bacteria  are  at  work, 
will  not  often  give  this  face..  Respiration  is  short  because  the  patient 
dreads  to  take  a  full  breath  which  would  cause  pressure  on  a  sensitve 
abdomen,  and  it  is  increased  in  frequency  in  order  that  the  full  func- 
tion of  the  lungs  will  continue  in  spite  of  the  limitation  of  working  sur- 
face, by  short  inspiratory  efforts.  TJie  tonic  spasm  of  t/ie  muscles  of 
the  abdominal  wall  continues  to  guard  the  contents  within,  but  a  certain 


46  Lcdtcrcs  on  Appendicitis. 

degree  of  exhaustion  of  the  muscles  is  indicated  by  less  responsive  ful- 
gurant  spasm  when  the  region  over  the  appendix  is  tapped  with  the 
finger.  This  plainly  tells  also  of  the  exhausting  effect  upon  the  patient 
of  continued  over-use  of  one  set  of  muscles — a  strain  which  a  strong 
man  who  is  not  being  undermined  by  bacteria  could  not  well  afford  to 
bear.  He  cannot  hold  an  ounce  weight  in  the  extended  hand  for  five 
minutes,  yet  he  must  suffer  contraction  of  the  abdominal  muscles,  per- 
haps for  days.  Peritoneal  lymph  coagulates  about  the  infected  appen- 
dix for  the  purpose  of  walling  it  in  so  well  that  the  bacteria  will  be 
confined  to  a  restricted  field,  and  the  subterfuge  is  successful  unless 
bacteria  have  gained  such  headway  that  they  attack  and  destroy  this 
wall.  The  pulse  and  temperature  are  still  unimportant  as  indicating 
the  actual  character  or  extent  of  the  destructive  process. 

Toxines  from  streptococci  may  excite  the  sympathetic  nerves  which 
control  the  muscles  of  the  arteries  and  heart,  and  stimulate  them  until 
the  pulse  is  full  and  bounding,  and  the  streptococci  may  cause  increased 
liberation  of  animal  force  in  the  form  of  heat,  so  that  the  temperature  is 
high  ;  or  a  more  destructive  process  may  be  taking  place  under  the  in- 
fluence of  colon  bacilli,  the  toxines  of  which  are  not  liberating  energy 
in  the  form  of  heat,  but  which  are  over-stimulating  the  sympathetic 
nerves  until  the  heart  cannot  relax  well  before  each  contraction,  and  we 
have  the  rapid,  feeble  pulse.  I  dread  a  normal  temperature  in  appen- 
dicitis more  than  a  high  temperature,  because  the  colon  bacilli  infect  so 
insidiously.  As  a  general  statement,  however,  it  is  best  to  say  that  the 
temperature  of  the  patient  must  be  entirely  left  out  of  our  calculation 
in  forming  an  estimate  as  to  the  condition  of  a  case  of  appendicitis. 

TYPICAL    CASE TENTH    DAY. 

(a)   Vital  signs  nearly  or  quite  normal. 

{b)  Appetite  returning. 

(r)  Bowels  moving  irregularly. 

(^)  Little  exudate  to  be  felt  about  the  appendix. 

[e)  Abdominal  walls  relaxed. 

TYPICAL     CASE TWENTIETH    DAY. 

(a)  Occupation  resumed. 

(^)  Tendency  to  constipation. 

{c)  Cautious  about  diet. 

(//)  A  little  tenderness  to  be  elicited  on  palpation  of  the  appendix. 

The  patient  is  inclined  to  be  constipated  because  sclerosis  of  the 
nerves  of  the  appendix  following  inflammatory  neuritis  disturbs  the 
branches  of  Auerbach's  plexus,  or  because  unabsorbed  lymph  adhesions 
inhibit  peristalsis,  beginning  at  the  cecum.  Dyspeptic  symptoms  appear 


Appendicitis.  4  7 

unless  the  patient  is  careful  about  his  diet,  because  the  disturbance  of 
the  branches  of  the  superior  mesenteric  plexus,  though  slight  in  charac- 
ter, is  quite  constant  in  effect,  and  intestinal  fermentation  is  consequent 
upon  incomplete  digestion.  Added  to  the  influence  of  sclerosis  of  the 
nerves  and  of  adhesions  which  put  a  hand  on  the  bowel,  there  is  a  con- 
stant and  mild  septic  impression  from  toxines  absorbed  through  the 
bared  lymphoid  coat  of  the  appendix  from  bacteria  which  are  living  in 
its  lumen. 

TYPICAL    CASE TWO    HUNDREDTH    DAY. 

Patient  feels  and  looks  well,  but  is  apt  to  use  tonics  to  overcome  the 
influence  of  constant  slight  toxine  absorption.  He  feels  the  need  of 
an  occasional  purgative,  and  from  time  to  time  there  is  a  little  sensation 
of  discomfort  in  the  right  inguinal  region,  from  involved  nerve  fila- 
ments, from  adhesions,  or  from  the  tense  appendix.  The  more  he 
feels  this  sensation,  the  more  frequently  he  tells  his  physician  and 
friends  that  he  is  perfectly  well,  hoping  to  thus  deceive  himself,  if  he 
knows  that  his  acute  attack  was  from  appendicitis.  If  he  is  unaware 
of  that  fact,  he  forgets  all  about  his  acute  attack  when  describing  symp- 
toms of  dyspepsia  and  constipation,  for  which  he  goes  to  his  physician 
for  relief. 

TYPICAL    CASE FOUR    HUNDREDTH    DAY. 

Second  acute  attack — bacteria  lurking  in  the  lumen  of  the  appendix 
again  excite  an  increase  of  interstitial  exudation,  and  having  handi- 
capped the  resistance  factors  are  making  incursions  into  the  tissues  of 
the  appendix  with  great  rapidity. 

Such  a  history  is  characteristic  of  a  case  of  appendicitis  under  medi- 
cal treatment.     Under  surgical  treatment  the  history  is  as  follows  : 

TYPICAL    CASE FIRST    DAY. 

[a)  Symptoms  of  appendicitis  sufficient  for  a  diagnosis. 

(/^)  Appendix  removed  through  an  inch-and-a-half  incision  with  em- 
ployment of  a  technique  which  buries  the  stump  of  the  appendix,  and 
closes  the  divided  layers  of  the  abdominal  wall  accurately. 

SECOND    DAY. 

(a)  Nausea  and  discomfort  from  the  effects  of  the  ether. 

{h)  Troublesome  colic  from  irritation  of  the  branches  of  Auerbach's 
plexus  by  the  operation. 

{c)  Formation  of  gas  in  the  bowel  from  failure  of  disturbed  sympa- 
thetic nerves  to  carry  on  assimilation  of  the  bowel  contents.  Hot 
peppermint  water  the  only  diet. 


48  Lcctitrcs  on  Appendicitis. 


THIRD    DAY. 


Perfectly  comfortable  when  lying  quietly  ;  reads  his  morning  paper 
in  bed  ;   general  diet  allowed. 

EIGHTH    DAY. 

Gets  out  of  bed  ;  feels  some  general  discomfort  in  the  right  inguinal 
region  ;  sits  in  a  chair  for  an  hour,  and  returns  to  bed,  but  does  not 
take  a  recumbent  position. 

NINTH    DAY. 

Walks  about  the  room  ;  little  discomfort. 

ELEVENTH    DAY. 

Assumes  his  occupation,  and  is  free  from  lingering  disturbance,  and 
from  all  danger  of  complications,  and  the  recurrence  of  appendicitis. 
Of  lesser  moment  is  the  fact  that  he  has  saved  time,  and  has  avoided 
several  days  of  unnecessary  discomfort. 


CHAPTER    IV. 

SURGICAL   TREATMENT    OF   APPENDICITIS. 

Five  years  ago  a  small  proportion  of  appendicitis  patients  were 
operated  upon  before  they  had  reached  the  life-or-death  stage  of 
septic  intoxication.  With  other  surgeons  I  have  tried  to  do  my 
part  in  taking  appendicitis  cases  out  of  the  life-or-death  class  and 
placing  the  operation  where  it  belongs — in  the  field  of  preventive 
medicine — not  preventive  in  the  sense  of  removal  of  the  normal 
appendix  for  the  purpose  of  avoiding  the  occurrence  of  appen- 
dicitis, but  rather  in  the  meaning  of  isolation  of  an  infected  ap- 
pendix before  it  has  infected  other  structures.  After  surgeons 
had  placed  the  operation  where  it  belonged,  medical  practitioners 
still  asked  their  patients  to  delay  operation,  and  endure  suffering 
and  loss  of  time,  besides  risking  an  addition  to  dark  statistics. 
Evidently  there  were  most  excellent  reasons  why  a  class  of  men 
who  habitually  and  by  training  guard  the  best  interests  of  the 
patient,  should  take  this  stand,  and  an  analysis  of  their  position 
seemed  to  reveal  these  several  elements,  viz. :  (i)  Any  given  at- 
tack of  appendicitis  was  likely  to  run  a  mild  course,  although  this 
could  not  be  foretold  from  the  symptoms  ;  (2)  occasionally  an 
appendicitis  patient  for  whom  a  simple  operation  had  been  per- 
formed, at  a  favorable  time,  suddenly  developed  alarming  symp- 
toms, and  died  ;  (3)  after  the  performance  of  surgical  operations 
upon  appendicitis  patients,  who  made  good  recoveries,  ventral 
hernias  began  to  appear  in  too  large  a  proportion  of  the  cases 
some  months  after  the  patients  believed  themselves  to  be  free 
from  all  complications  ;  (4)  unsightly  scars  were  depressing  in 
their  influence  on  patients  who  possessed  a  natural  vanity  as  to 
their  physical  perfection ;  (5)  the  patient  might  be  obliged  to 
waste  valuable  time  in  bed. 

It  remained,  then,  for  surgeons  to  perfect  a  technique  which 
would  eliminate  the  objections  to  prompt  operation  for  isolation 
of  the  infected  appendix,  and  such  objections  have  been  finally 
removed. 

4  49 


50  LcctiLves  on  Appendiciiis. 

(i)  The  best  surgical  operations  for  prompt  removal  of  an  in- 
fected appendix  are  now  less  to  be  dreaded  than  a  mild  attack  of 
appendicitis. 

(2)  Post-mortem  examination  in  certain  patients  who  died  after 
operation  .at  a  favorable  time,  showed  secondary  perforation  of 
the  stump  of  the  appendix  under  the  ligature.  The  stump  of  the 
appendix  could  not  be  tied  like  an  artery  and  left  without  further 
protection,  because  the  appendix  is  like  the  colon  in  structure, 
and  it  is  not  safe  in  making  lateral  anastomosis  after  resection 
of  a  colon  to  leave  the  free  ends  simply  occluded  with  ligatures. 
In  an  artery  we  have  an  aseptic  fluid  in  the  lumen  at  the  point 
of  ligature,  and  repair  goes  on  in  spite  of  compression-anemia 
under  the  ligature.  In  the  lumen  of  the  stump  of  the  appendix 
we  have  fluid  laden  with  bacteria,  which  are  quick  to  attack 
the  ring  of  tissue  disabled  by  compression-anemia  under  the 
ligature.  In  an  artery,  the  opposed  surfaces  of  the  tunica  intima 
become  adherent ;  in  an  appendix,  opposed  surfaces  of  mucosa 
or  of  bared  lymphoid  tissue  do  not  become  adherent.  The 
stump  of  the  removed  appendix  then  was  to  be  treated  like  the 
free  end  of  a  resected  colon  by  burying  the  stump  beneath  ap- 
proximated peritoneal  surfaces  which  would  effectually  seal-in  the 
weak  spot  in  a  few  hours.  Where  that  could  not  be  done  the 
stump  was  to  be  held  up  to  the  abdominal  incision  by  sutures  in 
the  cecum,  so  that  when  secondary  perforation  occurred,  bowel 
contents  would  have  a  short  route  for  external  escape.  Thus  was. 
eliminated  one  objection  to  operation. 

(3)  Ventral  hernias  following  appendix  operations  in  which  the 
wounds  were  entirely  closed,  were  due  to  one  potent  mechanical 
factor — the  gradual  drawing  apart  of  the  margins  of  the  incisions, 
in  the  transversalis  and  internal  oblique  muscles.  The  margins  of 
the  incision  were  drawn  widely  apart  in  the  normal  lines  of  trac- 
tion of  these  muscles  at  an  angle  to  the  common  line  of  incision  \ 
for  while  the  surgeon  is  at  work  the  margins  of  transversalis  and 
internal  oblique  muscles  contract  so  far  away  from  the  wound  that 
they  are  apt  to  be  imperfectly  united  at  final  suturing.  The  line 
of  incision  could  not  be  changed  to  meet  this  danger  because  that 
would  necessitate  transverse  section  of  the  external  oblique 
aponeurosis — a  structure  equally  important.  The  danger  of  ven- 
tral hernia  in  closed  wounds  after  an  appendix  operation  is  now 
obviated  by  adopting  a  plan  which  gives  a  complete  control  of 
the  elusive  margins  of  deeply  situated  muscles — I  refer  to  the  use 
of  the  "  guy-line,"  which  will  be  described  later. 


Surgical  Treatment  of  Appendicitis.  5  i 

(4)  Unsightly  scars  often  remained  after  operation,  because  of 
tradition  from  the  days  of  life-or-death  surgery;  it  seemed  un- 
necessary to  devote  time  to  a  neat  technique  which  would  do 
away  with  scar  marring  in  cases  where  the  surgeon  was  exultant 
over  his  success  of  saving  the  life  of  the  jiatient.  Now-a-days, 
when  we  state  that  a  certain  operation  belongs  to  the  field  of  pre- 
ventive medicine,  the  idea  includes  a  responsibility  on  the  part  of 
the  surgeon  to  leave  the  patient  in  as  good  condition  as  he  found 
him  ;  consequently  a  very  important  part  of  the  work  consists  in 
a  pretty  technique  for  cosmetic  effect. 

(5)  Patients  were  usually  obliged  to  spend  three  or  more  weeks  in 
bed  when  we  made  long  incisions  for  the  removal  of  infected  appen- 
dices, even  in  cases  in  which  the  wounds  could  be  entirely  closed 
by  suture.  The  time  required  for  repair  of  the  wound  means  pri- 
marily the  time  required  for  replacement  of  plastic  reparative 
lymph  by  normal  cells.  In  a  wound  one  quarter  of  an  inch  long, 
connective-tissue  cell  replacement  begins  in  a  few  hours,  if  bac- 
teria are  not  feeding  upon  the  lymph.  In  a  wound  one  foot  long, 
in  which  bacteria  are  not  feeding  upon  the  reparative  lymph,  re- 
pair is  delayed  because  of  the  extensive  injury  to  trophic  nerves, 
and  the  newly  repaired  structures  will  stretch  apart  if  much  pres- 
sure is  brought  to  bear  upon  them,  long  after  a  small  repaired 
place  would  resist  pressure ;  consequently,  a  wound  through  the 
abdominal  wall  one  quarter  of  an  inch  long  would  not  keep  the 
patient  in  bed  more  than  three  days,  while  a  wound  one  foot  long 
ought  to  keep  him  in  a  recumbent  position  for  three  weeks  at 
least. 

With  this  comparison  in  mind,  I  sought  to  take  the  mean  posi- 
tion by  making  as  short  an  incision  as  possible  in  the  abdominal 
wall  when  operating  for  the  removal  of  infected  appendices,  and 
I  found  after  a  few  trials  that  an  incision  one  and  a  half  inches  in 
length,  through  all  structures  of  the  abdominal  wall,  regularly 
gave  all  of  the  room  that  was  required  for  the  surgeon's  fingers 
and  for  instruments,  without  much  reference  to  the  size  of  the  pa- 
tient or  to  the  extent  of  the  adhesions.  Exceptional  cases  are  at 
once  quoted  by  surgeons  who  ask  the  questions  which  I  asked  my- 
self when  first  trying  the  short  incision,  and  which  was  settled  by 
practical  experience,  showing  that  for  every-day  work  the  inch- 
and-a-half  incision  is  sufficient.  This  incision  was  originally  in- 
tended for  cases  of  acute  infective  appendicitis  at  the  outset  of  an 
attack,  before  the  formation  of  extensive  adhesions,  but  it  was 
soon  found  that  it  sufificed  for  almost  all  of  my  "  interval  cases," 


52  Lectures  on  Appendicitis. 

no  matter  how  extensive  or  how  dense  the  adhesions.  The  tactile 
sense  was  to  be  trusted  more  than  the  eye.  The  only  important 
structures  which  can  be  ordinarily  injured  in  the  separation  of 
dense  adhesions  about  the  appendix  are  the  ureter,  bowel,  and 
iliac  vein.  "We  know  how  to  repair  an  injured  ureter  by  Van 
Hook's  method,  drawing  the  proximal  end  of  the  ureter  into  a 
slit  in  the  distal  end,  and  suturing  it  there.  It  is  not  difficult  to 
apply  the  Lembert  suture  or  the  Murphy  button  to  injured 
bowel,  and  a  rent  in  the  iliac  vein  can  be  repaired  by  suturing. 
I  have  not  injured  any  of  these  structures  when  guided  by  tac- 
tile sense,  but  have  injured  the  ureter  and  bowel  when  working 
by  sight  among  adhesions  through  a  long  incision.  There  is  no 
reason  why  we  should  not  abandon  the  inch-and-a-half  incision 
at  an3/  moment  when  it  seems  best  to  do  so,  but  the  number  of 
cases  in  which  this  incision  will  be  abandoned  will  become  less 
and  less  with  the  experience  of  each  surgeon.  I  have  seldom 
been  obliged  to  abandon  it  in  "interval  cases"  of  appendicitis. 
In  two  cases  in  which  the  opening  was  enlarged  the  appendix 
was  already  outside  of  the  abdominal  cavity.  In  one  case 
the  incision  was  enlarged  to  allow  of  accurate  suturing  of  the 
deep  muscles,  the  guy-line  not  having  been  employed  for  con- 
trolling them.  In  the  other  case,  I  did  not  know  that  the  ap- 
pendix was  already  outside  of  the  abdominal  cavity,  because  a 
dense  mass  of  adhesions  bound  it  closely  to  the  cecum,  and  not 
being  able  to  find  the  appendix,  the  incision  was  enlarged  by 
several  inches  for  further  exploration,  while  the  appendix,  to- 
gether with  the  cecum,  was  at  that  moment  being  held  in  my 
left  hand,  unwittingly  on  my  part,  outside  of  the  abdomen.  It 
is  quite  true  that  the  inch-and-a-half  incision  is  not  the  proper 
one  for  employment  by  the  surgeon  who  is  not  trained  in  adhesion 
work,  but  given  an  operator  who  is  familiar  with  peritoneal  adhe- 
sions, and  this  incision  allows  his  patients  to  escape  with  little  loss 
of  time,  and  Avith  no  danger  of  post-operative  ventral  hernia,  or  of 
marring  scars  in  the  cases  which  are  not  too  septic  for  close  sutur- 
ing of  the  wound. 

It  is  difficult  to  persuade  such  patients  that  they  must  remain 
in  bed  for  a  week.  I  formerly  kept  them  in  bed  for  seventeen  or 
eighteen  days  on  account  of  tradition,  but  one  of  my  gall-bladder 
patients,  with  a  two-inch  incision,  fell  dead  from  apoplexy  while 
walking  through  the  hallway  of  the  hospital  against  orders,  one 
week  after  the  operation,  and  on  removing  the  abdominal  wall 


Surgical  Treatment  of  Appendicitis.  53 

which  contained  the  scar,  I  tested  the  strength  of  strips  of  tissues 
which  inckided  the  scar,  and  determined  that  short-incision  pa- 
tients had  been  kept  too  long  in  bed.  The  inch-and-a-half  incision 
appendicitis  patients  were  then  allowed  to  get  out  of  bed  on  the 
eighth  day,  and  to  resume  their  occupations  on  the  tenth  or 
eleventh  day.  One  of  my  house  surgeons  suggested  that  this 
amounted  to  a  week-and-a-half  of  time  which  should  belong  to  the 
inch-and-a-half  incision.  It  is  unsafe  to  teach  the  use  of  the  inch- 
and-a-half  incision  in  suppurating  cases  of  appendicitis,  but  I 
occasionally  employ  it  even  in  such  cases,  and  know  that  many 
surgeons  guided  by  a  sufificient  degree  of  experience  can  do  like- 
wise. 

The  question  is  often  asked  if  an  incision  two  inches  long  Avould 
not  be  better  than  the  shorter  one.  The  smallest  amount  of  sur- 
gery which  is  suf^cient  for  the  accomplishment  of  a  certain  end  is 
the  best  for  the  patient.  The  inch-and-a-half  incision  is  sufificient 
for  routine  operative  treatment  in  the  every-day  appendicitis  work 
which  comes  to  us.  Every  half  inch  added  to  that  incision  in- 
creases the  time  to  be  spent  in  bed,  the  danger  of  post-operative 
ventral  hernia,  and  of  scar  marring.  There  is  no  occasion  to  make 
an  incision  of  any  definite  length  for  the  removal  of  ovarian  tumors, 
or  for  intestinal  resection,  or  for  any  of  the  common  intra-abdom- 
inal operations,  but  in  early  or  "  interval  "  appendicitis  cases,  on 
account  of  the  special  danger  of  post-operative  ventral  hernia,  due 
to  the  relative  positions  of  the  muscles,  there  is  special  need  for 
the  smallest  incision  which  will  allow  the  entrance  of  the  surgeon's 
finger's  and  exit  of  the  infected  appendix.  The  definite  length 
of  my  incision  having  reference  to  the  room  required  for  the  sur- 
geon's fingers  rather  than  to  the  size  of  the  patient,  or  the  extent 
of  the  adhesions,  is  therefore  preferable  to  a  long  incision. 
Through  the  inch-and-a-half  incision  I  have  resected  bowel  and 
have  made  intestinal  anastomosis  without  producing  any  of  the 
symptoms  of  shock  which  are  an  almost  invariable  accompaniment 
of  surgical  operations  in  which  the  bowel  is  much  handled  through 
a  long  incision.  The  short  incision  sometimes  requires  more  time 
for  the  surgeon,  but  it  saves  time  for  the  patient. 

The  Technique  of  the  I nch-and-a-Half  Incision. 

Step  I.  The  patient  is  given  five  grains  of  salol  to  limit  the 
extent  of  intestinal  fermentation  after  operation.  He  is  given  a 
hypodermatic  injection  of  codein  to  assist  in  thorough  anesthetiza- 


54  Lectin' €S  on  Appendicitis. 

tion,  and  to  quiet  disturbance  of  the  sympathetic  system  after 
operation.  If  codein  is  not  given  at  the  time  of  anesthetization, 
it  is  sometimes  ahnost  impossible  to  make  the  spasmodic  abdom- 
inal muscles  relax  under  the  most  complete  use  of  ether  or  chloro- 
form in  operations  which  disturb  the  superior  mesenteric  plexus. 
It  is  a  common  belief  that  the  nerves  of  the  anal  region  are  the 
last  to  succumb  to  the  influence  of  an  anesthetic,  but  the  supe- 
rior mesenteric  plexus  will  send  out  a  strong  reflex  to  the  muscles 
of  the  anterior  abdominal  wall  as  long  as  the  nerves  of  the  anal 
region  respond  to  stimulation. 

Step  II.  A  space  one  and  a  half  inches  in  length  is  measured 
off  on  the  patient's  abdomen  over  the  normal  site  of  the  appendix, 
and  in  a  line  which  follows  the  trend  of  the  external  oblique  apo- 
neurosis. The  distal  end  of  the  line  ends  at  the  right  margin  of 
the  right  rectus  abdominis  muscle.  A  scalpel  pierces  the  skin  at 
each  extremity  of  the  one-and-a-half-inch  line  in  order  to  mark  it 
well.     A  single  hooked  tenaculum  is  inserted  into  each  scalpel 


Fig.  25. — -Tenacula  inserted  into  scalpel  punctures  at  either  extremity  of  the  inch- 
and-a-half  line,  to  put  the  skin  upon  the  stretch  for  neat  incision  before  operation, 
and  for  accurate  suturing  after  operation. 

puncture,  and  by  means  of  two  tenacula  the  one  and  a  half  inches 
of  skin  lying  between  the  two  punctures  is  put  strongly  upon  the 
stretch.  The  reason  why  the  incision  is  made  in  the  line  of  the 
trend  of  the  external  oblique  aponeurosis  is  because  it  is  better  to 
split  that  aponeurosis  than  to  cross-cut  it ;  the  reason  why  the 
skin  should  be  put  upon  the  stretch  with  tenacula  is  because  an 
extremely  neat  division  of  skin  must  be  made  if  we  expect  to 
obtain  an  evanescent  scar  afterward. 

Step  III.  The  external  oblique  aponeurosis  having  been  split 
with  the  scalpel,  we  divide  in  the  same  line  the  aponeuroses  of 
the  internal  oblique  and  transversalis  muscles,  transversalis  fascia, 
and  the  peritoneum.  This  makes  a  cross-cut  of  the  transversalis 
and  internal  oblique  aponeurosis,  and  in  order  to  control  the 
margins  of  these  aponeuroses  after  their  muscles  have  drawn  them 


Surgical  Treatment  of  Appendicitis. 


55 


away  from  the  line  of  incision,  a  "  guy-line  "  is  inserted  at  the 
proximal  angle  of  the  wound  through  the  aponeuroses  of  the 
transversalis  and  internal  oblique  muscles,  and  through  the  trans- 
versalis  fascia  and  peritoneum.  The  guy-line  is  a  strong  strand 
of  catgut,  and  after  it  is  inserted  an  ordinary  forceps  is  snapped 
on  the  loose  end  and  left  there   until  we  are  ready  to  close  the 


r 


e- 


Fig.  26. — Deep  aponeuroses  brought  into  view  by  means  of  the  guy-line.  The 
cecum  fills  the  middle  space  in  the  illustration,  and  the  external  oblique  aponeurosis 
margins  have  slid  away  on  either  side  of  the  deeper  aponeuroses,  which  are  pulled  up 
ready  for  accurate  suturing. 


wound.  The  weight  of  the  artery  forceps  hanging  by  the  patient's 
side  keeps  the  guy-line  out  of  the  way  during  the  remainder  of 
the  operation.  When  we  are  ready  to  close  the  wound,  an  assist- 
ant, making  strong  traction  on  the  guy-line,  pulls  the  retracted 
margins    of    the  divided   transversalis   and    internal   oblique  apo- 


56 


LecHtres  on  Appendicitis. 


neuroses  up  into  sight  so  easily  that  they  can  be  sutured  with  per- 
fect accuracy.  The  suture,  which  is  a  continuous  one  of  small 
chroinicized  catgut,  includes  the  cut  margins  of  peritoneum  and 
transversalis  fascia  at  the  same  time.     Some  operators  have  tried 


Fig.   27. — Aponeuroses  involved  in  appendicitis  operations. 
A.   External  oblique  aponeurosis.  B.   Internal  oblique  aponeurosis. 


to  split  the  transversalis  and  internal  oblique  muscles  instead  of 
making  a  cross-cut  through  them,  the  so-called  "  criss-cross  opera- 
tion." It  is  necessary  to  make  an  unnecessarily  large  incision 
and    to   hold  the  margins  of  the  divided   external   oblique  apo- 


Surgical  Treatme7tt  of  Appendicitis. 


57 


neurosis  out  of  the  way  with  retractors  for  that  operation.  The 
external  oblique  aponeurosis  is  scantily  supplied  with  blood  from 
vessels  running  through  the  loose  connective-tissue  planes  above 
and  below  it,  and  if  we  hold  its  margins  out  of  the  way  with  re- 


FlG.  28. — C.    Transversalis  aponeurosis. 


tractors  the  vascular  connections  are  so  injured  that  semicircular 
portions  of  the  external  oblique  aponeurosis  corresponding  to  the 
parts  that  are  pulled  aside  with  retractors  are  quite  likely  to  either 
slough  or  become  absorbed  later,  thus  leaving  a  weak  spot  in  the 
abdominal   wall  at   the   site   of  operation.     In    such   a   case    the 


58  Lectures  on  Appendicitis. 

Avouncl  heals  by  primary  union  at  first,  but  at  the  end  of  a  few 
days  there  is  evidence  of  suppuration  beneath  the  skin,  and  on 
opening  the  wound  for  drainage,  and  examining  the  margins  of 
the  external  oblique  aponeurosis,  we  find  them  blue,  ragged,  and 
sloughing.  This  accident  does  not  happen  in  the  Bassini  hernia 
operation,  so  far  as  my  observations  go,  because  at  that  point  the 
external  oblique  aponeurosis  receives  a  fairly  good  blood  supply. 
In  the  Halsted  hernia  operation  we  approach  the  danger  line,  but 
at  the  site  of  operation  for  the  removal  of  an  appendix  the  ex- 
ternal oblique  aponeurosis  is  so  poorly  supplied  with  blood  that 
we  must  be  extremely  cautious  about  separation  of  the  loose  con- 
nective-tissue attachments  with  retractors  in  operations  in  which 
this  work  is  to  be  done.  Sloughing  of  semicircular  margins  of 
external  oblique  aponeurosis  occurred  in  two  of  my  earlier  opera- 
tions, and  I  believe  that  surgeons  must  abandon  operations  which 
involve  this  feature. 

Step  IV.  If  the  appendix  is  not  at  once  felt  by  the  finger  in- 
serted into  the  abdominal  cavity,  the  ascending  colon  or  cecum  is 
pulled  up  through  the  wound.  Colon  and  cecum  are  recognized  by 
the  senses  of  touch  and  sight.  They  are  much  lighter  in  color 
than  the  ileum,  and  are  definitely  distinguished  by  three  whitish 
muscular  longitudinal  bands  which  one  can  see  plainly  without 
trained  powers  of  observation.  These  three  whitish  longitudinal 
muscular  bands  lead  straight  to,  and  end  exactly  at,  the  appendix, 
so  that  no  one  could  well  miss  it  unless  extensive  adhesions  had 
deeply  covered  the  bowel.  Where  adhesions  deeply  cover  the 
bowel,  the  cecum  and  colon  can  be  differentiated  from  other  struc- 
tures by  the  sense  of  touch,  but  that  requires  some  training,  and 
is  not  to  be  described.  If  one  is  in  doubt  as  to  which  direc- 
tion to  follow  the  longitudinal  muscular  bands  in  order  to  arrive 
at  the  appendix,  he  can  excite  a  reversed  peristalsis  of  the 
bowel  by  touching  it  with  a  little  chloride  of  sodium  if  the 
bowel  is  not  stiffened  with  interstitial  exudate ;  but  in  most 
of  our  appendicitis  cases  this  valuable  resource  of  intestinal 
surgery  is  neither  useful  nor  necessary  as  the  appendix  is 
pretty  sure  to  be  very  near  the  incision,  and  on  pulling  the  bare 
ascending  colon  out  through  the  wound,  the  transverse  colon, 
marked  by  omentum,  is  soon  reached  if  one  is  seeking  in  the 
wrong  direction.  In  a  case  in  which  the  cecum  cannot  be  freed 
from  adhesions  sufficiently  to  allow  us  to  pull  it  out  through  the 
incision,  I  usually  hunt  for  the  appendix  by  inserting  one  finger 


Surgical  Trcaime^it  of  Appendicitis.  59 

through  adhesions  between  the  viscera  and  the  pelvic  Avail,  keep- 
ing close  to  the  wall,  and  separating  the  adherent  viscera  frr^ni  it 
in  a  mass.  The  appendix  is  very  likely  to  lie  against  the  pelvic 
"wall,  and  a  little  experience  will  teach  one  to  recognize  it  in  the 
midst  of  the  conglomerate  mass  of  other  structures.  13y  the  sense 
of  touch,  one  can  gradually  work  out  the  appendix  and  bring  it 
to  the  surface.  If  the  conglomerate  mass  is  not  too  large,  I 
often  bring  it  out  upon  the  abdominal  wall,  in  a  lump  through 
the  inch-and-a-half  incision,  and  then  enucleate  the  appendix  from 
other  structures.  Any  part  of  the  appendix  having  been  found, 
the  remainder  can  be  readily  separated  from  adhesions. 

Step  V.  The  appendix  having  been  cleared  from  adhesions,  a 
catgut  ligature  is  used  for  ligating  the  mesappendix,  and  that 
structure  is  then  cut  loose.  The  muscular  and  peritoneal  coats 
of  the  appendix  are  divided  in  a  circle  close  to  the  cecum,  leaving 
the  inner  tube  of  lymphoid  tissue  and  mucosa  uncut.  The  inner 
tube  is  then  ligated  with  a  strand  of  fine  eye-silk,  and  the  ap- 
pendix is  amputated  distally  from  the  ligature.  The  inner  tube 
alone  is  ligated  because  that  will  suf^ce  for  closing  the  lumen  of 
the  appendix,  and  the  free  margins  of  the  muscular  wound  in  the 
stump  will  carry  on  repair  over  the  weak  point.  Silk  is  used  for 
ligating  the  inner  tube  because  it  makes  a  tiny  knot,  which  re- 
mains longer  in  place  than  a  catgut  knot  of  the  same  size. 

The  next  thing  in  order  is  to  bury  the  stump  of  the  appendix 
by  bringing  the  walls  of  the  cecum  together  over  it  with  three  or 
four  Lembert  sutures.  The  opposed  peritoneal  surfaces  will  ad- 
here in  a  few  hours  so  firmly  that  no  harm  will  result  if  the  stump 
perforates  under  the  ligature  because  it  is  effectually  sealed  in.  It 
is  better  to  scarify  the  surfaces  of  peritoneum  which  are  to  close  in 
a  buried  appendix  stump.  If  the  Avails  of  the  cecum  are  so  stiff 
or  fragile  with  interstitial  exudate  that  the  stump  of  the  ap- 
pendix cannot  be  pushed  in  and  buried,  the  cecum  is  brought  up 
against  the  abdominal  Avail,  and  sutured  to  the  margins  of  the 
incision,  so  that,  if  secondary  perforation  takes  place,  bowel  con- 
tents will  escape  through  a  small  drainage  opening  in  the  abdomi- 
nal incision  Avhich  is  left  open  for  that  purpose.  If  the  cecum 
cannot  be  closed  over  the  stump,  or  brought  up  against  the  ab- 
dominal Avail  with  sutures,  a  drain  canal.  Availed  off  Avith  aristol,  is 
left,  leading  from  the  cecum  to  the  drainage  opening  in  the  ab- 
dominal Avail,  in  expectation  of  a  possible  secondary  perforation 
at  the  stump.     Cases  in  Avhich  the  stump  of  the  removed  appen- 


6o  LccttLTCs  on  Appendicitis. 

dix  cannot  be  neatly  buried  are  the  exception  in  the  class  of  cases 
which  make  up  our  every-day  appendix  work  at  the  present  time. 
Before  closing  the  abdominal  incision,  dry  aristol  is  rubbed  into 
the  ragged  tissues  which  mark  separated  adhesions,  for  the 
purpose  of  preventing  septic  infection  or  immediate  re-adhesion 
at  such  points. 

Step  VI.  When  we  are  ready  to  close  the  abdominal  incision,, 
an  assistant  pulls  up  strongly  on  the  guy-line,  and  that  brings 
into  plain  view  the  margins  of  the  internal  oblique  and  trans- 
versalis  aponeuroses,  the  transversalis  fascia,  and  peritoneum. 
All  of  these  structures  are  closely  approximated  with  one  con- 
tinuous suture  of  catgut.  If  any  one  attempts  to  close  the  inch- 
and-a-half  incision  without  using  the  guy-line  or  some  equally 
good  contrivance,  the  operation  as  I  have  planned  it  is  a  failure,, 
and  one  of  the  prettiest  operations  in  surgery  is  brought  into 
discredit.  The  keystone  of  the  inch-and-a-half-incision  method 
is  the  guy-line. 

After  the  deep  structures  of  the  wound  have  been  closed  with 
the  continuous  suture,  the  guy-line  is  cut  away,  and  the  margins 
of  the  external  oblique  aponeurosis  are  approximated  with  two 
or  three  interrupted  sutures  which  penetrate  into  the  deeper  layer 
of  tissues  beneath,  so  that  scantily  nourished  margins  of  aponeu- 
rosis will  fit  snugly  and  thus  receive  nutrition  by  contact.  The 
sutures  which  are  placed  in  the  external  oblique  aponeurosis  must 
not  be  tied  tightly  because  of  the  danger  of  compression-anemia, 
which  would  interfere  with  good  repair  in  a  structure  w'hich  needs 
such  care  on  the  part  of  the  surgeon. 

Step  VII.  The  last  step  in  the  operation  consists  in  closing 
skin  and  fat  in  such  a  way  as  to  make  an  evanescent  scar,  and 
this  cannot  be  done  unless  tenacula  are  again  inserted  into  the 
angles  of  the  wound,  and  the  skin  put  upon  the  stretch  until 
skin  margins  are  drawn  absolutely  together  without  wrinkling, 
and  without  the  interposition  of  any  subcutaneous  fat.  A 
fine  Hagedorn  needle  and  a  continuous  suture  of  very  small 
catgut  are  used  for  uniting  the  closely  approximated  skin  mar- 
gins. The  needle  and  suture  include  the  whole  thickness  of  the 
true  skin,  and  nothing  else  besides  the  skin.  If  any  fat  is  in- 
cluded in  the  suture,  it  will  slowly  give  way  under  pressure.  The 
sutures  then  being  looser,  the  margins  of  skin  Avill  draw  apart  a 
trifle,  and  the  intended  effect  is  lost.  The  scar  will  draw  out  into 
a  broad  line  within  a  few  wrecks,  and  will  remain  permanently  as 


Surgical  Treatment  of  Appendicitis. 


6i 


a  scar.  The  patient  will  not  be  ready  to  get  out  of  bed  on  the 
eighth  day,  and  to  resume  his  occupation  a  week  and  a  half  after 
the  date  of  operation.  I  do  not  include  fat  in  any  suture  for  the 
complete  closure  of  any  abdominal  incision.     Before  the  last  loop 


Fig.  2g. — Evanescent  scar  following  the  inch-and-a-half  incision. 


of  catgut  is  tied  in  the  continuous  skin  suture,  the  fat  layers  are 
approximated  by  manual  pressure  applied  on  the  outside  of  the 
wound.  Any  blood  or  irrigating  fluid  is  forced  out  by  such  pres- 
sure. The  last  loop  is  tied,  and  after  that  the  fat  margins  remain 
together  by  atmospheric  pressure  as  securely  as  the  boy's  leather 
sucking  disk  clings  to  a  stone,  and  on  the  same  principle.     Many 


62  Lectures  on  Appendicitis. 

of  us  overlooked  for  years  the  role  Avhich  atmospheric  pressure 
could  be  made  to  play  in  evenly  approximating  thick  layers  of 
adipose  tissue  in  a  closed  wound.  In  order  to  make  sure  of  an 
evanescent  scar  it  is  well  to  use  catgut  which  will  be  absorbed  in 
about  ten  days,  and  then  the  function  of  sutures  is  carried  on  for 
ten  days  more  by  a  strip  of  gauze  laid  upon  the  scar  line,  and 
saturated  with  flexible  collodion.  The  collodion  gauze  prevents- 
a  stretching  out  of  the  new  repair  tissue.  A  wound  so  treated 
may  be  at  the  end  of  a  year  entirely  invisible  on  ordinary  inspec- 
tion, and  it  is  a  triumph  of  artistic  surgery  as  compared  with  the 
scars  of  the  days  of  life-or-death  surgery.  My  plan  for  obtaining" 
an  evanescent  scar  and  for  making  adipose  wound  margins  remain 
approximated  by  atmospheric  pressure  was  developed  about  four 
years  ago. 

TJic  TccJiniqiie  in   the  Treatment  of  Appendicitis  with  Widespread 

Infection. 

Step  I.  If  the  patient  is  pulseless,  or  very  weak  from  over- 
whelming septic  intoxication,  it  is  well  to  obtain  a  pulse  with 
hypodermatic  injections  of  strychnia,  if  possible,  before  operating. 
In  some  moribund  cases  a  very  fair  pulse  will  appear  under  the 
influence  of  ether  alone,  but  strychnine  is  invaluable  in  such  cases. 

Step  II.  The  patient  is  placed  in  Trendelenburg's  posture, 
unless  the  surgeon  has  become  very  expert  in  treating  compli- 
cated septic  abdominal  cases,  and  is  guided  by  highly  trained 
tactile  sense.  Trendelenburg's  posture  allows  the  operator  to 
work  very  easily  by  sight,  and  much  unnecessary  handling  of 
bowel  is  avoided  because  atmospheric  pressure  packs  the  bowel 
so  well  out  of  the  Avay  when  the  abdomen  is  opened  that  loops  of 
intestine  are  not  constantly  bulging  into  the  field  of  work. 
Trendelenburg's  posture  may  be  obtained  without  having  a  special 
table  for  the  purpose,  if  a  long-backed  chair  is  placed  face  down 
upon  an  ordinary  table,  and  the  patient  is  pulled  up  on  the  inclined 
plane  made  by  the  back  of  the  chair  until  his  legs  hang  over  the 
rounds,  and  keep  him  from  sliding  down  the  incline.  Before  the 
abdomen  is  opened  the  bowels  will  be  observed  to  gravitate 
towards  the  diaphragm  if  a  proper  degree  of  inclination  has 
been  given  to  the  patient. 

Step  III.  An  incision  three  or  four  inches  long  is  made  in  the 
line  of  the  trend  of  the  external  oblique  aponeurosis,  the  incision 
traversing  the  normal  site  of  the  appendix. 


Surgical  Treatment  of  Appendicitis.  6 


o 


Variety  A,  Step  IV.  If  there  is  general  septic  peritonitis  ^vith- 
out  adhesions,  the  appendix  will  be  found  stiff  and  hard,  bobbing 
about  in  peritoneal  fluid  unless  it  has  already  sloughed.  The 
appendix  having  been  removed,  the  whole  abdominal  cavity  is 
flushed  out  with  a  few  quarts  or  gallons  of  hot  physiological  saline 
solution  at  a  temperature  of  about  ioo°  F.,  inserted  through  a 
long  tube  of  large  calibre. 

Variety  B,  Step  IV.  If  the  general  peritoneal  cavity  is  filled  with 
pus  and  loose  lymph  flakes,  one  or  two  pints  of  hydrogen  dioxide 
are  first  injected  into  various  parts  of  the  abdominal  cavity  for 
breaking  up  clinging  pus  and  lymph,  and  two  or  three  minutes 
later  the  whole  abdominal  cavity  is  flushed  out  with  a  few  gallons 
of  hot  physiological  saline  solution. 

Variety  C,  Step  IV.  When  the  abdominal  cavity  is  filled  with 
masses  of  infected,  coagulated  lymph,  which  cause  general  adhe- 
rence of  the  viscera,  with  or  without  multiple  pools  of  liquefied 
lymph,  the  surgeon's  hand  must  be  inserted  and  carried  over  the 
whole  abdominal  cavity,  to  separate  all  adhesions  before  using 
hydrogen  dioxide  and  physiological  saline  solution,  as  in  Variety 
B.  The  patient  will  probably  die  while  this  is  being  done,  but  I 
kept  one  such  patient  alive  by  holding  a  bottle  of  nitrite  of  amyl 
constantly  to  his  nose  until  all  adhesions  were  separated  and  the 
abdominal  cavity  flushed  out.  This  patient  was  moribund,  apa- 
thetic, and  pulseless  half  an  hour  before  operation,  but  a  slight 
strychnine  pulse  was  obtained,  and  the  patient  recovered,  but 
still  carries  a  fecal  fistula  due  to  the  sloughing  of  gangrenous 
patches  of  colon. 

Variety  D,  Step  IV.  When  a  walled-in  abscess  is  found  in  the 
inguinal  region,  the  abscess  cavity  is  very  thoroughly  cleansed 
with  hydrogen  dioxide  and  flushed  out  with  saline  solution.  This 
allows  us  to  search  for  the  appendix,  and  for  multiple  abscesses 
in  the  vicinity,  without  danger  of  infecting  the  general  peritoneal 
cavity  when  that  is  exposed  through  separated  adhesions.  I  be- 
lieve that  the  danger  of  infecting  the  general  peritoneal  cavity  in 
this  way  is  greatly  overestimated,  judging  from  a  pretty  full  per- 
sonal experience  with  such  cases,  but  nevertheless  I  do  not  neglect 
to  throw  about  the  case  all  of  the  precautions  which  belong  to 
tradition.  In  olden  times  we  rested  content  with  the  opening  of 
one  abscess  in  such  cases,  and  some  of  the  patients  died  because 
another  and  smaller  abscess  remained  hidden  away  in  adhesions. 
Other  patients   died  because  an   infected    mass  of  appendix  re- 


64  Lectures  oil  Appendicitis. 

mained  to  cause  slow  jDoisoning.  The  question  as  to  whether  any 
given  appendix  is  to  be  removed  or  left  in  such  a  case  must 
always  remain  a  question  for  decision  by  the  particular  operator 
who  is  at  work,  and  who  knows  whether  his  qualifications  make  it 
safer  or  more  dangerous  for  that  particular  patient  to  have  an 
adherent  appendix  removed.     There  is  no  rule  in  the  matter. 

Variety  E,  Step  I  J".  If  a  swollen,  fragile  appendix  cannot  be 
separated  from  adhesions  without  tearing  it  to  pieces,  it  may  be 
split  with  the  handle  of  a  scalpel,  and  the  lymphoid  tissue  and 
mucosa  are  then  removed  with  a  curette,  if  any  portions  of  such 
structures  have  remained.. 

Step  V.  When,  after  the  removal  of  the  appendix,  it  is  found 
that  the  cecum  is  too  fragile  to  hold  sutures  for  burying  the 
stump,  or  too  badly  disorganized  to  resist  necrotic  changes,  the 
cecum  is  brought  up  to  the  abdominal  wall  and  sutured  to  one 
margin  of  the  abdominal  incision  in  such  away  that  the  intestinal 
contents  will  escape  immediately  through  the  drainage  opening 
when  the  cecum  gives  way  a  few  days  later.  If  sloughs  have 
formed  in  colon  or  ileum,  such  damaged  bowel  is  sutured  to  the 
anterior  abdominal  wall  near  the  incision,  and  for  the  same  rea- 
son. In  cases  in  which  the  cecum  cannot  be  brought  up  against 
the  anterior  abdominal  wall,  aristol  is  rubbed  on  the  presenting 
structures  which  are  to  form  the  wall  of  the  drainage  canal  lead- 
ing from  damaged  cecum  to  the  anterior  abdominal  wall.  The 
aristol  in  a  few  minutes  walls  off  a  canal  so  well  that  the  patient 
is  safe  against  infiltration  infection  among  intestinal  loops,  or 
along  the  planes  of  the  structures  of  the  abdominal  wall. 

Step  JV.  A  drainage  wick  not  quite  as  large  round  as  the  littie 
finger,  and  surrounded  by  gutta-percha  tissue,  is  inserted  as  far  as 
the  iliac  fossa,  or  into  the  pelvis,  to  obtain  capillary  drainage. 
The  capillary  gauze  drain  will  have  done  work  enough  at  the  end 
of  twenty-four  hours,  and  may  then  be  removed.  The  drainage 
canal  will  be  by  that  time  so  well  walled  in  that  discharges  from 
below  will  escape  readily  to  the  surface,  as  a  rule.  If  there  is  any 
doubt  on  that  point,  it  will  be  well  to  carry  a  single  narrow  strip 
of  gutta-percha  tissue  to  the  bottom  of  the  wound  on  the  end  of 
a  probe,  and  this  will  further  act  by  capillarity — capillarity  be- 
tween the  walls  of  the  drainage  canal  and  the  line  of  least  resist- 
ance along  the  smooth  gutta-percha.  In  my  work  there  are 
three  things  which  are  particularly  avoided — the  use  of  drainage 
tubes,   counter-openings  for   drainage,   and   gauze    packing.     No 


Surgical  Treatment  of  Appendicitis.  65 

one  can  question  the  value  of  the  drainage  tube  in  the  practice  of 
the  Prices,  but  it  forms  a  part  of  tlieir  system,  which  system  as  a 
whole  has  given  most  brilliant  results.  I  do  not  use  the  drainage 
tube  because  the  hydrostatic  pressure  of  a  column  of  fluid  in  the 
tube  needs  to  be  relieved  by  constant  attention  on  the  part  of 
trained  nurses  or  assistants,  and  the  mechanical  effect  of  such 
pressure  in  the  neglected  tube  is  to  keep  the  structures  at  the 
bottom  of  the  tube  bathed  in  fluid,  for  the  counter-pressure  of 
viscera  is  not  sufificient  to  fully  overcome  hydrostatic  pressure. 
By  turning  the  power  of  capillarity  into  use,  we  may  make  it 
take  the  place  of  counter-openings  for  drainage.  Counter-open- 
ings add  more  surgery  to  a  class  of  cases  in  which  the  patient 
must  be  asked  to  bear  as  little  surgery  as  possible.  With  a  small 
drainage  wick  sucking  away  at  any  point  in  the  lower  part  of  the 
abdominal  or  pelvic  cavity,  the  opposed  peritoneal  planes  must 
exert  capillary  power  at  any  distance,  and  draw  free  fluid  from  all 
directions  toward  the  point  at  which  the  greatest  force  is  con- 
stantly being  exerted.  There  is  nothing  theoretical  in  my  views 
on  this  point.  They  are  based  on  the  most  practical  results 
gained  in  every-day  work  with  a  class  of  cases  in  which  it  would 
seem  as  though  separate  collections  of  fluid  must  form  in  various 
dependent  parts  of  the  abdominal  cavity.  I  wish  to  have  as  few 
foreign  bodies  as  possible  in  the  abdominal  cavities  of  my  appen- 
dicitis patients  after  operation,  feeling  that  if  a  large  drainage 
tube  were  placed  in  my  own  abdominal  cavity  this  morning,  I 
would  not  feel  Avell  to-morrow  morning;  and  a  weak  patient  is 
no  stronger  than  I  am.  Several  drainage  tubes  placed  through 
counter-openings  make  a  heavier  load  yet  for  the  patient.  On 
this  same  ground  I  do  not  use  gauze  packing  in  the  abdominal 
cavity.  A  mass  of  gauze  packing  in  my  own  abdominal  cavity 
to-day  would  interfere  with  my  work  by  to-morrow.  Gauze  pack- 
ing is  soon  filled  with  lymph,  which  coagulates  and  fills  the 
meshes,  because  the  mechanical  effect  of  the  absorbent  dressing 
on  the  outside  of  the  abdomen  is  not  suf^cient  to  lift  fluids  rap- 
idly through  the  large  absorbent  mass  belov/.  The  coagulating 
lymph  causes  peritoneal  surfaces  to  adhere  firmly  to  the  gauze 
packing,  so  that  when  it  is  removed,  the  healing  tissues  are  rudely 
disturbed,  and  intestinal  loops  are  pulled  into  all  sorts  of  malpo- 
sition. Worst  of  all  is  the  result  of  leaving  a  large  surface  to  be 
attacked  by  streptococci  when  the  gauze  packing  is  removed. 
Colon   bacilli  apparently  stop  work  on  exposure  of  their  nests, 


66  Lectures  on  Appendicitis. 

and  then  streptococci  and  other  bacteria  take  their  place  and 
poison  the  patient  by  slow  septicemia,  if  the  surgeon  cannot 
take  good  enough  precautions  against  their  ravages.  The  cavity 
left  after  removal  of  the  gauze  packing  is  a  particularly  favorable 
nidus  for  the  development  of  streptococci.  Iodoform  gauze  is 
still  less  useful  than  plain  absorbent  gauze,  because  the  iodoform 
and  the  substances  employed  for  fixing  it  in  the  gauze  interfere 
with  its  capillarity,  which  is  already  handicapped  when  the  drain 
is  too  large.  A  fallacy  appears  in  the  reasoning  against  the  use  of 
large  stiff  drainage  tubes,  and  of  gauze  packing,  if  we  make  one 
comparison,  and  say  that  a  septic  wound  minus  harmful  drainage 
apparatus  is  more  dangerous  than  a  septic  wound  plus  harmful 
drainage  apparatus — a  statement  which  is  quite  true  ;  but  harmful 
drainage  apparatus  can  be  supplanted  by  harmless  resources,  A 
drainage  wick  which  is  small,  soft,  and  supple,  and  which  adjusts 
itself  to  curves,  yielding  to  the  pressure  of  bowel  in  various  direc- 
tions, and  constantly  at  work  by  capillary  power,  does  not  produce 
much  disturbance  in  the  abdominal  cavity,  and  it  drains  well 
for  as  long  a  time  as  large  tubes  and  gauze  packing  drain  poorly. 
All  sorts  of  drains  are  soon  walled  off  in  the  abdominal  cavity  by 
peritoneal  exudate,  and  their  usefulness  then  ceases.  It  is  some- 
times stated  that  blood-clot  will  not  pass  through  a  drainage 
wick,  but  neither  will  blood-clot  pass  through  a  drainage  tube  ; 
fluid-blood  will  pass  out  through  a  capillary  wick  (not  through 
gauze  packing)  before  it  has  time  to  clot,  and  more  readily  than  it 
will  pass  out  through  a  drainage  tube.  Pus  will  not  pass  through 
the  drainage  wick  freely,  but  I  do  not  use  either  wick  or  tube  for 
draining  off  pus  from  wounds  in  soft  parts,  depending  rather  upon 
pressure  of  tissues  to  force  pus  to  follow  the  line  of  least  resist- 
ance. In  cases  where  pus  is  to  be  drained  off,  a  single  narrow 
strip  of  gutta-percha  tissue  often  helps  to  guide  the  fluid  along 
the  line  of  least  resistance. 

Step  VII.  Inclosing  a  long  incision  the  steps  are  practically  the 
same  as  in  closure  of  the  inch-and-a-half  incision,  with  the  excep- 
tion that  an  opening  is  left  for  the  drainage  wick,  and  aristol  is 
rubbed  into  the  opening  about  the  wick  in  order  to  wall  off  the 
various  tissue  planes  against  infiltration.  A  small  drainage  open- 
ing left  in  the  abdominal  incision  is  preferable  to  a  larger  one 
unless  we  need  to  give  exit  to  intestinal  contents  from  more  than 
one  sloughing  point  in  bowel.  I  always  inform  patients  that  they 
are  quite  likely  to  have  a  ventral  hernia  at  the  site  of  an  appen- 


Surgical  Treaimait  of  Appendicilis.  67 

dicitis  operation  if  the  wound  has  been  drained,  because  the  trans- 
versahs  and  internal  oblique  muscles  draw  their  margins  steadily 
away  from  the  site  of  the  unsutured  drainage  opening,  and  be- 
cause the  nerves  which  supply  the  muscles  in  the  vicinity  of  the 
wound  do  not  then  get  their  ends  together.  For  the  same  reason 
it  is  difficult  to  repair  such  a  hernial  opening,  because  the  tissues 
for  reconstruction  of  the  abdominal  wall  at  that  point  are  not 
there.  The  resource  of  suturing  the  cecum  to  the  abdominal  wall 
at  the  site  of  operation  has  prevented  the  formation  of  ventral 
hernias  in  all  of  my  drained  appendicitis  wounds,  in  which  it  was 
employed,  because  the  cecum  remains  attached  there,  fixed  in  the 
weakest  point,  and  it  shunts  loops  of  bowel  that  would  otherwise 
work  through. 

Step  VIII.  When  the  drainage  wick  is  removed,  twenty-four  hours 
after  the  operation,  the  treatment  consists  in  injecting  balsam  of 
Peru  into  the  drainage  canal  twice  daily.  If  there  is  a  large  amount 
of  purulent  discharge,  I  use  hydrogen  dioxide  before  injecting  the 
balsam,  until  granulations  form,  but  the  hydrogen  dioxide  must 
then  be  omitted  because  of  its  tendency  to  follow  leucocytes  into 
the  granulation  tissue.  When  a  drainage  canal  has  contracted  to 
form  a  narrow  sinus,  all  suppuration  can  sometimes  be  stopped 
abruptly  by  one  injection  of  iodoform  and  glycerine  in  the  pro- 
portions of  one  to  ten,  the  walls  of  the  granulating  sinus  then 
adhering  by  secondary  union.  After  long  incision  operations,  it 
is  best  to  keep  the  patient  in  the  recumbent  position  for  at  least 
three  weeks. 

Step  IX.  After  any  operation  for  appendicitis,  with  either  the 
long  or  short  incision,  I  give  nothing  but  hot  water  or  hot  pepper- 
mint water  for  twenty-four  hours,  because  the  process  of  digestion 
is  inhibited  by  the  disturbance  of  the  abdominal  sympathetic 
nerves,  and  fermentation  of  the  bowel  contents  ensues,  with  the 
production  of  gas,  which  may  cause  much  distress,  and  the  toxines. 
are  irritating.  Saline  cathartics,  which  are  hygroscopic,  are  passed 
through  the  alimentary  tract,  or  injected  into  the  colon  by  high 
enemata  on  the  day  after  the  operation  for  the  purpose  of  causing 
rapid  exosmosis  of  intra-peritoneal  toxine-bearing  fluids,  and  car- 
rying off  toxines  and  gas.  The  process  is  repeated  as  often  as 
septic  symptoms  call  for  it.  If  the  colon  is  much  distended  with 
gas,  it  is  emptied  through  a  long  rectal  tube.  If  the  Stomach  is 
also  distended  with  gas,  it  is  emptied  through  a  long  stomach 
tube.     This  can  be  easily  accomplished  with  little  repugnance  on 


68  Lectures  on  Appendicitis. 

the  part  of  the  patient  if  the  stomach  tube  is  first  lubricated  with 
palatable  sweet  oil  flavored  with  oil  of  wintergreen,  and  presented 
to  the  patient  in  a  clean  white  saucer,  the  patient  being  asked  to 
chew  the  tube,  and  to  swallow  it  at  leisure.  The  oil  of  winter- 
green  tastes- so  good  that  the  patient  swallows  the  tube  with  a 
relish.  The  fauces  may  be  first  sprayed  with  cocaine  if  the  pa- 
tient is  particularly  sensitive.  While  I  am  very  much  opposed  to 
the  use  of  opium  after  abdominal  operations  as  a  rule,  there  are 
places  in  which  the  unrest  and  over-stimulation  of  the  sympathetic 
system  can  be  quieted  Avith  codein  to  the  advantage  of  the  patient, 
provided  that  we  do  not  allow  the  peritoneum  and  bowel  to  stop 
work. 

The  dietary  and  general  treatment  for  the  comfort  of  the  patient 
after  operation  I  prefer  to  leave  to  the  family  physician,  if  it  is 
possible  for  him  to  be  in  attendance,  and  to  share  the  pleasure 
and  work  of  carrying  a  distressing  case  of  appendicitis  to  complete 
recovery. 


ONE  HUNDRED  CONSECUTIVE  OPERATIONS  FOR  APPENDICITIS. 

A  list  of  consecutive  appendicitis  operations,  beginning  with 
my  first  and  ending  Avith  my  one  hundredth  case,  is  here  given  as 
illustrative  of  the  progress  that  was  made  by  the  appliance  of 
new  resources.  If  some  of  the  first  cases  could  be  replaced  by  a 
series  operated  upon  subsequently  to  this  group  the  list  would 
include  fewer  fatal  cases,  but  would  not  be  so  valuable  for  pur- 
poses of  instruction.  The  reason  why  there  were  so  few  opera- 
tions done  at  the  outset  of  the  first  attack,  is  because  I  have  no 
clientele  of  my  own,  and  the  patients  came  to  me  from  physicians 
who  had  tried  palliative  treatment  first.  Latterly  there  has  been 
a  larger  proportion  of  early  infection  cases,  and  these  Avill  be  in- 
cluded in  reports  to  be  made  elsewhere. 


Surgical  Ti^catvient  of  Appendicilis. 


69 


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Hernia      appeared 
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Hernial    opening 
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Sepitic  peritonitis. 

Another     case     in 
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Operation. 

Incision   i^  inches  long.      Re- 
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stump.     Closed  wound. 

Incision  i^  inches   long.      Re- 
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stump.      Closed  wound. 

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stump.     Closed  wound. 

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stump.     Drained  wound. 

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hesions.   Adhesion  band  from 
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Surgical  Treatment  of  Appendicitis.  8 1 

Sitimnary. 

Fifty-nine  of  the  cases  belonged  to  the  interval  or  early-infection 
class,  and  although  many  of  them  involved  complicated  adhesion  work 
there  were  no  deaths  in  the  series. 

Seven  of  the  cases  were  of  peritoneal  tuberculosis,  involving  the 
appendix,  and  apparently  having  origin  at  the  appendix  in  six  of  them. 
All  recovered  from  the  operation.  Three  recovered  and  three  others 
are  recovering  from  the  peritoneal  tuberculosis.  In  one  the  tuber- 
culosis continued. 

One  case  of  cancer  involved  the  appendix  and  cecum.  I  exsected 
all  of  the  cancerous  structures,  and  the  patient  has  had  no  recurrence 
of  the  disease  to  date.     Fourteen  months  elapsed. 

Six  cases  of  intense  general  septic  peritonitis,  with  the  whole  abdom- 
inal cavity  bathed  in  a  flood  of  pus,  were  of  the  type  that  belonged  to 
the  most  fatal  class  until  very  recently.  In  this  group,  however,  I  lost 
only  one  case,  the  moribund  patient  dying  of  shock  two  hours  after 
the  operation. 

Four  cases  with  intense  general  septic  peritonitis  not  marked  by  the 
presence  of  pus  gave  two  deaths.  One  of  these  cases  (No.  29  in  the 
list)  does  not  really  belong  in  these  statistics  at  all,  as  the  case  was  one 
of  gangrene  of  a  strangulated  ileum,  but  it  must  be  included  because  I 
happened  to  remove  the  appendix,  which  was  right  at  hand  and  which 
was  valuable  as  a  peculiar  specimen,  though  it  had  no  bearing  on  the 
outcome  of  the  case.  The  other  death  resulted  from  bowel  obstruction, 
in  a  case  in  which  the  whole  serosa  had  apparently  been  destroyed  by 
the  peritonitis. 

Twenty-three  cases  were  of  the  walled-off  abscess  form,  presenting 
the  most  varied  complications,  from  that  of  a  small  excapsulation 
of  pus  up  to  abscess  cavities  containing  quarts  of  pus  in  one  or  more 
compartments  and  reaching  from  the  pelvis  to  the  liver,  but  sep- 
arated from  the  remaining  uninfected  peritoneal  cavity  by  protecting 
lymph  walls.  There  were  five  deaths  in  this  group.  Two  of  them  in 
my  first  two  appendicitis  cases,  tube  drainage  having  been  used  and 
the  resources  of  hydrogen  dioxide  and  saline  solution  not  employed. 
Both  patients  died  of  septicemia.  Three  of  the  patients  died  after  I 
had  adopted  wick  drainage  and  the  use  of  hydrogen  dioxide  and  saline 
solution.  One  of  these  died  of  acute  suppurative  nephritis,  which  be- 
gan a  few  hours  before  the  operation.  Another  died  of  intestinal 
obstruction  from  adhesions  which  could  not  be  separated  at  the  time 
of  operation  on  account  of  the  patient's  condition  ;  and  the  third  one, 
weak  from  several  months  of  septicemia,  died  of  shock. 

If  the  seven  appendicitis  patients  in  this  list  who  died  could  have  had 

6 


82  Lectures  on  Appendiciiis. 

the  benefit  of  the  methods  resulting  from  a  fuller  experience  I  believe 
that  three  of  them  would  have  recovered.  I  feel  that  the  death-rate  in 
one  hundred  such  cases  as  this  list  contains  should  not  be  more  than  four 
or  five  per  cent.,  notwithstanding  the  fact  that  many  of  the  cases  were  in 
a  condition  which  seemed  almost  to  prohibit  operative  interference. 

Ventral  /icr?iia  has  appeared  in  only  two  of  the  cases,  because  of  my 
method  of  closing  the  abdominal  wound.  One  of  the  hernias  appeared 
in  an  inch-and-a-half-incision  case  which  had  to  be  drained,  and  the 
hernial  opening  has  since  been  closed  by  secondary  operation.  The 
other  hernia  appeared  in  one  of  the  general  suppurative  peritonitis 
cases,  in  which  a  long  incision  had  to  be  kept  widely  open.  This 
hernia  is  controlled  by  a  truss,  as  it  cannot  be  easily  corrected  by 
operation. 

Fecal  fistula  has  persisted  in  one  case  only  (No.  15),  and  there  are 
two  cases  of  superficial  fistula  which  the  patients  do  not  wish  to  have 
repaired  as  yet. 

Mistakes  in  diagnosis  were  seldom  made  in  suspected  cases  of  appen- 
dicitis. Thus,  in  the  series  of  one  hundred  cases  everything  is  included 
in  which  I  made  a  diagnosis  of  appendicitis  before  the  operation,  and 
error  was  made  but  three  times.  No.  17  had  a  normal  appendix  sur- 
rounded by  adhesions,  due  to  typhoid  perforation  of  the  bowel.  No.. 
43  had  a  normal  appendix  in  a  case  of  general  peritoneal  tuberculosis.. 
No.  67  had  cancer  of  the  cecum,  involving  the  appendix.  The  con- 
sequences of  these  three  mistakes  in  diagnosis  are  as  follows  : 

(i)  The  patient  with  typhoid  adhesions  has  been  decidedly  benefited 
by  separation  of  the  adhesions  which  had  caused  constipation  almost. 
to  the  point  of  obstruction. 

(2)  The  peritoneal  tuberculosis  patient  is  cured. 

(3)  The  cancer  patient  is  perfectly  well  to  date,  fourteen  months 
after  the  operation,  with  no  sign  of  recurrence  as  yet. 

No  doubt  the  proportion  of  cases  in  which  one  would  find  difficulty 
in  making  a  diagnosis  is  larger  in  a  general  medical  practice,  for  almost 
all  of  the  appendicitis  cases  which  are  sent  to  the  surgeon  have  first 
been  differentiated  as  such  by  the  general  practitioner,  and  that  gives, 
the  surgeon  an  evident  advantage.  Then,  again,  the  proportion  of  • 
appendicitis  cases  in  a  general  medical  practice  fluctuates  markedly. 
One  physician  of  my  acquaintance  has  had  sixteen  cases  of  appendicitis 
during  the  past  five  years,  diagnosis  having  been  verified  by  operation 
in  all  of  them.  Another  physician  of  large  practice  assures  me 
that  he  has  never  seen  a  case  of  appendicitis.  The  death-rate  in  cases 
of  appendicitis  treated  without  operation  fluctuates  also.  Thus,  one 
physician  has  recently  reported  fourteen  attacks  of  appendicitis  in  four- 
teen patients  treated  medically,  with  six  deaths.    Another  reports  eighty- 


Surgical  Treatment  of  Appendicitis.  83 

five  cases  with  fourteen  deaths,  and  another  reports  twenty  cases 
without  a  death.  I  would  like  details  in  such  a  report.  In  this  con- 
nection I  wish  to  say  that,  the  expressions  '*  case  "  and  "  attack  "  must 
not  be  used  synonymously,  because  we  are  to  expect  that  "  when  one 
attack  is  done  the  patient's  troubles  have  just  begun."  Statistics 
from  countries  in  which  appendicitis  is  classed  as  typhlitis  cannot  be 
used  by  us.  I  have  been  through  the  wards  of  large  European  hos- 
pitals and  have  been  shown  series  of  typhlitis  cases  which  included 
ordinary  catarrhal  colitis,  coprostasis,  and  tuberculous  enteritis,  but 
not  appendicitis.  Data  bearing  upon  the  subject  of  appendicitis 
should  be  collected  only  from  physicians  who  differentiate  these  cases 
distinctly. 

I  hope  that  another  century  will  see  the  establishment  of  a  medical 
court  with  a  judiciary  which  has  no  other  occupation  than  weighing 
evidence  and  giving  rulings  upon  that  large  part  of  medical  knowledge 
which  can  be  classified. 

If  judges  upon  the  same  bench  sometimes  find  it  difficult  to  know 
what  is  good  law,  how  much  more  difficult  must  it  be  for  the  members 
of  our  profession  to  deduce  the  truth  and  the  right  from  a  mass  of  in- 
complete testimony  and  hearsay  evidence  that  is  presented  to  us  in 
good  faith  by  medical  advocates,  but  which  requires  for  correct  analy- 
sis a  judicial  temperament  and  long  training  in  methods.  Yet  every 
one  of  us  is  assumed  to  be  not  only  a  judge  but  a  good  one  and  im- 
partial. Matters  of  fact  that  have  been  settled  beyond  all  peradventure 
in  one  locality  are  bandied  about  as  subjects  for  debate  in  other  locali- 
ties. If  nothing  more  than  property  were  involved  this  would  be  a 
matter  of  comparatively  small  moment,  but  human  life  is  directly  at 
stake,  because  physicians  must  carry  into  practice  their  individual  de- 
cisions. From  appendicitis  to  vaccination  and  from  antitoxine  to  vivi- 
section there  are  questions  which  demand  rulings  from  a  local,  state^ 
national,  and  international  medical  court. 


CHAPTER  V. 

NOTES. 

THE  ACTION  OF  VARIOUS  SOLVENTS  ON 
GALLSTONES. 

Four  years  ago  I  experimented  with  various  gallstone  solvents 
for  the  purpose  of  simplifying  the  operation  in  cases  in  which  an 
impacted  gallstone  is  found  in  the  common  duct,  my  intention 
being  to  avoid  the  operation  of  section  of  the  duct,  or  the  danger 
of  injury  to  the  duct  in  crushing  a  gallstone  in  position,  by  inject- 
ing solvents  through  a  soft  catheter  introduced  into  the  common 
duct ;  the  gall-bladder  having  first  been  fastened  to  the  skin  to 
form  a  fistula.  Now,  however,  with  the  use  of  aristol  to  wall  off 
a  drainage  canal,  and  the  use  of  the  drainage  wick  to  draw  away 
bile  rapidly  by  capillarity,  the  operation  has  been  reduced  to  such 
a  simple  one  that  I  do  not  care  to  follow  out  the  idea  of  dissolv- 
ing impacted  stones;  but  the  experiments  which  were  made  at 
that  time  as  to  the  solubility  of  gallstones  are  interesting.  The 
object  was  to  find  a  liquid  w4iich  could  be  best  applied  through 
a  temporary  biliary  fistula  ;  hence,  solvents  destructive  to  living 
tissues  were  excluded,  and  the  experiments  were  therefore  limited 
to  gallstones  consisting  largely  of  cholesterin,  since  there  seemed 
no  possibility  of  dissolving  inorganic  concretions  with  noncorro- 
sive  solvents. 

The  solvents  tried  were  divided  into  four  classes,  viz. : 
(i)  General  solvents. — Liquids  known  to  possess  the  power  of 
dissolving   many    organic   substances    of  different   constitutions. 
These  include  the  "  text-book  solvents,"  or  those  mentioned  in 
the  books  as  readily  dissolving  cholesterin. 

(2)  Natural  solvents. — Those  which  are  said  to  hold  cholesterin 
in  solution  in  the  body. 

(3)  Allied  solvents. — Those  which,  being  akin  to  cholesterin  in 
chemical  constitution,  should,  according  to  the  law  of  "like  dis- 
solves like,"  be  good  solvents  for  cholesterin. 

(4)  Indicated  solvents. — Those  which  being  akin  in  chemical 
constitution  to  solvents  found  to  act  well,  are  those  indicated  as 
possibly  able  to  act  better. 

84 


Gallstone  Solvents. 


85 


The  general  organic  solvents  are:  Acetic  acid,  acetic  ether, 
acetone,  alcohol,  amyl  alcohol,  benzene,  carbon  bisulphide,  chlo- 
roform, ether,  petroleum  ether  or  naphthol  (three  kinds  were  used), 
and  xylol.  Ether  is  excluded  as  it  boils  below  blood  heat.  All  the 
others  were  tried,  as  were  also  glycerine,  paraffin  oil,  and  olive  oil. 

The  natural  solvents  are  the  soaps  (salts  of  the  fatty  acids — two 
kinds  were  used)  and  the  salts  of  the  bile  acids. 

The  allied  solvents.  Since  cholesterin  is  a  benzene  derivative, 
and  contains  a  hydroxyl  group,  and  is  nearly  allied  to  the  turpenes 
and  camphors,  the  following  solvents  were  tried:  turpentine  oil, 
eucalyptol,  phenol,  naphthol  (alpha  and  beta),  disolved  in  alcohol, 
menthol  in  carbon  bisulphide,  Caucasian  petroleum. 

The  indicated  solvents  are  bromoform,  carbon  tetrachloride, 
and  ethylene  dichloride,  which  were  used  because  chloroform  was 
found  to  be  a  good  solvent.  Other  substances  used  were  chloral 
hydrate  and  alcoholate,  for  either  of  these  mixed  with  camphor  lique- 
fies it.     But  they  were  found  to  be  without  action  on  cholesterin. 

Altogether  twenty-nine  solvents  were  used.  The  gallstones 
examined  were  from  six  patients : 

(i)  Black  stones  ;  ash  small. 

(2)  Yellow-brown  stones  ;  ash  small. 

(3)  Gray  stones ;  ash  small. 

(4)  Brown  stones  ;  ash  large. 

(5)  Yellow-gray  stones  ;  ash  small. 

(6)  White  stones  ;  ash  small. 

The  first  experiments  were  made  with  set  No.  i,  and  the  others 
were  tried  as  specimens  were  obtained.  As  it  seemed  most 
desirable  to  use  a  natural  solvent,  soaps  were  first  tried.  Pre- 
liminary experiments  showed  that  their  solvent  power  was 
slight.     Thus : 

GALLSTONES SET    NO.    I. 


Solvent. 

Temperature. 

Time.                 j         Action. 

Ivory  soap  dissolved  in  water 

Strong  solution 

TOO°C. 

looX. 

27X. 

37°C. 

37°C. 
38°C. 
38X. 

I  min. 

3  min. 

72    hrs. 

46    hrs. 

45    hrs. 
2i  hrs. 
24  hrs. 

Slight. 
Sli-^ht 

Same  solution 

Slight. 

Ivory  soap  dissolved  in  20  per  cent, 
alcohol , 

Ivory  soap  dissolved  in  20  per  cent, 
alcohol 

brokeup  on 
shaking. 
No  change. 

Slight. 

Castile  soap  dissolved  in  20  per  cent. 

alcohol 

Castile  soap  dissolved  in  20  per  cent. 

alcohol 

86  Notes. 

Preliminary  experiments  were  tried  with  a  number  of  other 
solvents,  with  the  result  that  glycerine  and  menthol  were  rejected. 
Experiments  were  next  tried  with  weighed  stones  and  measured 
liquids.  To  obtain  an  equal  weight  of  solid  for  use  with  each 
solvent  it  would  have  been  necessary  to  cut  or  powder  the  stones, 
but  it  semed  better  to  test  them  fn  the  natural  state,  though  this 
made  necessary  the  use  of  stones  of  unequal  weight  for  the  various 
tests.  To  diminish  the  effect  of  this  difference  on  the  results,  a 
large  excess  of  the  solvent  was  used — always  the  same  volume  of 
each  solvent  in  each  set  of  experiments.  The  method  was  to 
note  the  time  at  which  the  solvent  and  the  stone  were  brought 
together;  then  to  plunge  the  test  tube  containing  them  in  an  oil- 
bath,  kept  in  an  incubator  at  blood  heat,  and  to  note  at  intervals 
the  appearance  of  the  stone.  In  this  way  tables  were  made,  from 
which  the  final  result  is  copied  below.  The  action  was  taken  as 
complete  when  the  stone  was  thoroughly  broken  up,  for  it  is 
unnecessary  that  it  should  be  completely  dissolved  ;  and  this  is 
the  time  given  in  the  table  below.  At  first  the  effect  was  not 
noted  at  very  short  intervals,  so  that  here  "  the  time  "  is  only  the 
maximum  result.  In  later  experiments  the  effect  was  noted 
every  minute  for  the  first  few  minutes,  and  later  at  gradually 
increasing  intervals. 

AT    BLOOD    HEAT. 

/ 
GALLSTONES SET    NO.    I. 


Solvent. 


Alcohol  and  acetic  acid 
Alcohol  and  potash  .  . . 

Benzene 

Carbon  bisulphide .... 
Carbon  bisulphide .... 
Carbon  tetrachloride  .  . 

Chloroform 

Eucalyptol 

Paraffin  oil 

Petroleum  (American). 
Petroleum  (Caucasian). 

Phenol 

Xylol 


Weight. 


.021  gm. 
.020 
.020 
.030 
.016 
.020 
.017 
.019 
.018 
.023 
017 
.017 
.023 


Time. 


7  mm. 


48  hrs.  plus. 
27  hrs.  plus. 
24  hrs.  minus. 

1.30 

1.30 

o  hrs. 
24  hrs. 
27  hrs. 
27  hrs. 
24  hrs. 
27  hrs. 
4S  hrs. 
24  lirs. 


Dissolved 
per  minute. 


.0003 

.00015 

.003 


Gallstone  Solvents. 


87 


GALLSTONES SET    NO.     2. 


Alcohol  and  acetic  acid 
Alcohol  and  potash  .  .  . 

Benzene 

Carbon  bisulphide 

Carbon  bisulphate 

Carbon  tetrachloride. . . 

Chloroform 

Eucalyptol 

ParafiSn  oil 

Petroleum  (American) . , 
Petroleum  (Caucasian). 

Phenol 

Xylol 


Weight. 


.023  gm. 

.024 

.025 

.020 

.016 

.020 

.047 

.021 

.024 

.023 

.018 

.024 

.020 

.027 


Dissolved 
per  minute. 


48  hrs. 
27  hrs. 

o  hrs. 

o  hrs. 

O  hrs. 

o  hrs. 

O  hrs. 

0  hrs. 
2  hrs. 

27  hrs. 

24  hrs. 

2  hrs. 

48  hrs. 

1  hrs. 


plus, 
plus. 
56  min. 
15  min. 

6  min. 

5  min. 
15  min. 
15  min. 
15  min. 
plus. 

15  min. 


.0005 

•0013 

.0027 

.004 

.003 

.0014 


.0004 


GALLSTONES — SET    NO.    2. 


Solvent. 

Weight. 

Time. 

Dissolved 
per  minute. 

.033  gm. 

.077 

•034 

■037 

.029 

.029 

.074 

21  hrs. 

0  hrs.  7  mm. 

0  hrs.    7  min. 

0  hrs.   3  min. 
19  hrs. 
19  hrs. 

3  hrs.  plus. 

Carbon  tetrachloride 

Chloroform 

.005 

Naphthol  in  alcohol  (beta) 

Petroleum  (Caucasian) 

GALLSTONES SET    NO.    3. 


Solvent. 


Carbon  bisulphide . . 
Carbon  tetrachloride 
Chloroform 


Weight. 


.076  gm. 

.038 

•039 


Time. 


O  hrs.  10  min. 
O  hrs.  7  min. 
o  hrs.      5  min. 


Dissolved 
per  minute. 


.008 
.005 
.012 


From  the  column  giving — for  the  best  solvents  only — the 
weight  dissolved  per  minute,  it  is  seen  that  these  are  carbon  bisul- 
phide and  tetrachloride,  and  chloroform.  These  were  therefore 
more  closely  compared  in  testing  the  remaining  gallstones,  and 
bromoform  and  ethylene  dichloride  were  also  tried.  It  was  found 
that  the  gallstones  in  set  No.  4,  which  contained  much  inorganic 
substance,  were  not  much  attacked  by  any  of  the  solvents,  although 
some  of  them  were  deeply  colored  by  these  stones. 


iVoies. 


GALLSTONES  —  SET    NO.    5. 


Solvent. 

Weight. 

Time. 

Dissolved 
per  minute. 

Bromoform. .  .  .  ." 

.o?35  gm. 

.064 

.025 

.065 

.061 
.029 
.0215 

0  hrs.   30  min. 

12  min. 

6  min. 

12  min. 

15  min. 

12  min. 

6  min. 

.0008 

Carbon  bisulphide 

.005 
.004 

.005 

.004 

.0024 

■0035 

Carbon  bisulphide    10  per  cent,  and 

tetrachloride  10  per  cent 

Carbon  bisulphide   50  per    cent,  and 

Chloroform 

GALLSTONES SET    NO.    6. 


Solvent. 


Bromoform 

Carbon  bisulphide , 

Carbon  bisulphide 

Carbon  bisulphide  go  per  cent,  and  tetra- 
chloride, 10  per  cent 

Carbon  bisulphide  90  per  cent,  and  chlo- 
roform  10  per  cent 

Carbon  tetrachloride 

Chloroform 


Weight. 


.032.  gm. 

.020. 

.031. 

.020. 

.025. 
.029. 
.027. 


Time. 


24  mm.  .0013. 

I  min.  .020. 

not  much  attacked. 


Dissolved  per 
minute. 


2  mm. 

3  min. 
8  min. 
3  min. 


.008. 

.0036. 

.oog. 


Carbon  bisulphide  and  chloroform  still  surpass  all  others,  and  the 
addition  of  carbon  tetrachloride  to  the  bisulphide  is  seen  to  be  no 
improvement.  The  two  best  solvents  were  now  particularly  com- 
pared with  regard  to  their  action  on  gallstones  in  set  No.  i. 


GALLSTONES SET    NO.     I. 


Solvent. 


Weisht. 


Carbon  bisulphide 
Carbon  bisulphide 
Carbon  bisulphide 

Chloroform 

Chloroform 

Chloroform 


.024. 
.020. 

.145- 
.024. 
.020. 
•154. 


Time. 


55  mm- 
42  min. 
23  min. 
60  min. 
70  plus. 
35  plus. 


Dissolved   per 
minute. 


.0005)  mean. 

.005)       .023. 

.070) 

.0004)  mean. 

.0003)     .015. 

.044) 


Here  it  is  seen  that  the  large  stones  were  dissolved  in  much 
less  time  than  the  small  ones ;  that  the  time  for  unit  weight 
should  be  less  in  the  case  of  the  large  stones  is  comprehensible, 
for  the  proportion  of  the  outer,  deeply  colored,  difficultly  soluble 
layer  is  less.  Besides  the  thorough  breaking  up  of  the  large  stone 
does  not  involve  its  breaking  into  such  small  pieces  as  are  obtained 


Gallstone  Solvents. 


89 


from  a  small  stone.  But  this  would  hardly  account  for  the  differ- 
ence observed.  It  seems  probable  that  the  larger  stones  are  less 
compact  than  the  smaller  ones,  /.  c.  that  they  have  a  lower  specific 
gravity.  But  it  must  not  be  forgotten  that  the  smaller  stones  of 
the  same  set  differ  enormously  in  themselves — witness  the  failure 
of  chloroform  on  a  small  No.  i  stone  in  set  No.  i,  and  the  failure 
of  bisulphide  in  a  stone  in  set  No.  6.  These  results  place  carbon 
bisulphide  at  the  head  of  the  list. 

Pure  cholesterin  was  next  prepared  and  tested  with  the  solvents. 
It  was  found  that  there  was  such  a  parallel  between  its  solubility 
and  that  of  the  gallstones  that  new  solvents  might  fairly  be  tested 
with  it  instead  of  with  the  stones.  The  solvents  dissolved  choles- 
terin in  the  following  order,  small  quantities,  approximately  equal, 
being  used  in  test  tubes  : 

Carbon  bisulphide — instantly  on  touching. 

Chloroform — almost  instantly. 

Carbon  tetrachloride — almost  instantly. 

Bromoform — almost  instantly. 

Ethylene  dichloride — more  slowly. 

Benzene — more  slowly  still. 

Xylol — about  as  benzene. 

Turpentine — more  slowly. 

Amyl  alcohol — more  slowly  than  turpentine. 

Alcohol — slowly. 

The  petroleum  had  little  action  ;  paraffin  oil  and  glycerine, 
none. 

On  the  strength  of  this  parallel,  the  solvents  acetone,  acetic 
ether  and  olive  oil,  and  gall  acids  were  rejected  because  they  had 
but  little  action  on  cholesterin.  The  acids  were  especially  pre- 
pared from  ox-gall,  and  dissolved  in  alcohol.  Their  potassium 
salts  were  also  tried. 

A  conspectus  of  the  action  of  the  best  solvents  on  the  dif- 
ferent stones   is  as  follows : 

GALLSTONES SET.    NO.     I. 


Solvent. 

Stone  I. 

Stone  2. 

Stone  3. 

Stone  5. 

Stone    6. 

T^Iean. 

Carbon  bisulphide.  . 

Chloroform 

Carbon     tetrachlo- 
ride   

.023. 
.015. 

.003. 

.0065. 
.0065. 

.004. 

.008. 
.012. 

.005. 

.0045. 
.0035. 

.0024. 

.020. 
.oog. 

.0036. 

.0124. 

.oog. 

90 


Notes. 


Conchisions. 

The  best  solvent  is  carbon  bisulphide,  though  for  some  stones 
chloroform  may  prove  better  (see  stone,  set  No.  3).  A  mixture 
of  the  two  iri  equal  quantities  would  probably  have  the  best  gen- 
eral effect.  Stones  from  the  same  subject  differ  enormously  in 
solubility,  as  much  as  do  stones  from  different  subjects ;  but  in 
the  latter  case  the  difference  is  regular,  in  the  former  only  occa- 
sional. Any  solvent  which  will  not  instantly  dissolve  cholesterin 
may  be  rejected  as  a  solvent  for  gallstones,  although  it  is  possi- 
ble that  a  solvent  may  readily  dissolve  cholesterin  and  yet  not 
act  readily  on  gallstones.  This  gives  a  ready  means  of  testing 
any  solvents  which  may  suggest  themselves.  We  have  no  evi- 
dence that  gallstones  are  ever  dissolved  by  substances  taken 
internally  for  that  purpose  by  patients.  Olive  oil  is  very  fre- 
quently administered.  There  are  several  reasons  why  it  does  not 
act  therapeutically  as  a  solvent,  (i)  Oil  cannot  be  expected  to 
travel  up  the  gall-ducts  from  the  duodenum  because  the  peristaltic 
action  of  the  ducts  is  toward  the  duodenum  from  the  liver,  and 
this  peristaltic  action  is  presumed  to  be  unceasing.  (2)  If  oil 
could  travel  against  the  peristaltic  effort  of  the  gall-ducts  and 
enter  an  open  gall-bladder — many  are  not  open — it  would  be  at 
once  mixed  with  bile.  (3)  Undiluted  sweet  oil  in  which  I  kept 
gallstones  for  weeks  at  various  temperatures  produced  no  appre- 
ciable effect  beside  a  softening  of  the  external  layers  of  some 
stones.  So  unimportant  was  its  action,  that  it  was  not  thought 
worth  while  to  include  it  in  the  further  tests. 

What  sweet  oil  does  do  is  to  carry  toxines  out  of  the  alimen- 
tary tract  pretty  rapidly,  and  it  relieves  patients  of  the  element 
of  intoxication  from  that  source.  The  fact  that  biliary  colic  often 
ceases  after  the  administration  of  sweet  oil  is  a  coincidence  to  be 
expected  if  we  simply  remember  that  such  colic  ceases  as  quickly 
without  the  aid  of  sweet  oil.  Biliary  colic  means  extraordinary 
efforts  on  the  part  of  the  muscular  walls  of  the  gall-bladder  and 
ducts  to  force  out  an  irritating  substance,  and  the  colic  ceases 
when  a  stone  has  passed  out  of  the  canal  or  when  it  has  failed  to 
engage  and  has  moved  back  into  the  gall-bladder,  where  it  may 
remain  quiescent  for  days,  months,  or  years. 

Drugs  given  internally,  on  the  theory  that  they  will  prevent 
any  further  formation  of  gallstones,  are  handicapped  if  gallstone 
formation  is  due  to  fermentation  of  mucus  in  the  biliary  tracts, 
because  fermentation  is  caused  by  bacteria  only;  and  the  colon 


Gallstone  Solvents.  91 

bacillus,  which  is  apparently  the  principal  culprit,  is  not  influenced 
so  far  as  we  know  by  any  drug  after  that  drug  has  been  exposed 
to  digestive  processes  and  has  been  excreted  by  the  liver.  Post- 
mortem examination  of  patients  who  were  supposed  to  have  been 
cured  of  gallstones  has  revealed  the  fact  that  stones  were  still  in 
the  gall-bladder.  Personally,  I  would  much  prefer  to  depend 
upon  our  successful  new  surgical  resources,  rather  than  suffer  the 
agony  of  a  single  attack  of  gallstone  colic,  in  the  hope  that  some 
fanciful  line  of  treatment  might  reach  and  dissolve  a  set  of  gall- 
stones snugly  hidden  away  in  the  gall-bladder.  Medical  treat- 
ment which  would  aim  to  prevent  the  formation  of  gallstones 
must  apparently  have  for  its  first  object  the  prevention  of  the 
development  of  colon  bacilli  in  the  gall-bladder,  and  we  have  no 
available  resources  for  that  purpose  as  yet. 


THE  INFLUENCE  OF  REMAINS  OF  THE  EMBRYONIC 
VITELLINE  DUCT  IN  THE  PRODUCTION  OF  MOIST 
NAVELS,  AND  OF  ECZEMATOID  INFLAMMATION 
ABOUT    THE    NAVEL. 

The  primitive  intestine  and  the  umbilical  vesicle  in  the  human 
embryo  are  in  connection  through  the  vitelline  duct  until  the 
abdominal  plates  close  at  about  the  end  of  the  sixth  week  of  fetal 
life,  and  shut  in  that  part  of  the  duct  which  unites  navel  and 
umbilical  intestinal  loop.     The  umbilical  intestinal  loop  having 


Fig.  30. — Microscopic  section  from  eczematoid  navel,  showing  mucous  follicles 
developed  from  embryonic  remains. 

been  drawn  into  the  abdominal  cavity,  subsequent  development 
of  the  alimentary  tract  causes  rupture  or  thinning  of  the  remains 
of  the  vitelline  duct,  which  should  then  become  absorbed.  Some- 
times omphalo-mesenteric  remains,  instead  of  undergoing  absorp- 

92 


Embryonic  Remains.  93 

tion,  become  developed  in  whole  or  in  part,  and  form  intestinal 
diverticula ;  open  intestinal  fistulse  at  the  navel ;  fibrous  intra-ab- 
dominal bands,  with  or  without  mesenteric  blood-vessels  ;  intra- 
abdominal retention  cysts;  and  so-called  adenomata  of  the  navel, 
consisting  of  hypertrophic  intestinal  gland  tissue.  Such  well 
defined  structures  have  attracted  the  attention  of  many  observers, 
but  there  is  another  and  larger  class  of  cases  in  which  microscop- 
ical remains  of  the  vitelline  duct  at  the  navel  cause  annoying 
complications,  which  do  not  present  features  pointing  to  their 
real  origin.  Tiny  embryonic  remains  at  the  navel,  which  develop 
columnar  epithelium  or  tubular  glands,  may  empty  their  secretions 
externally,  and  this  mucus,  though  small  in  amount,  is  sufficient 
to  keep  the  navel  and  the  skin  in  its  vicinity  constantly  moist.  In 
children  with  delicate  skins,  the  exposed  mucus  decomposes,  and 
sometimes  causes  an  irritation  resulting  in  dermatitis,  or  "  eczema 
of  the  navel,"  which  may  extend  to  the  formation  of  a  reddish, 
angry-looking  patch  as  large  as  the  hand,  just  as  it  does  from  the 
secretion  from  a  patent  urachus.  Such  a  dermatitis  is  rather 
intractable  under  the  ordinary  plans  of  treatment  because  the 
original  cause  persists,  and  though  palliative  treatment  will  lessen 
or  control  the  amount  of  irritation,  there  is  a  tendency  toward 
exacerbations  of  local  dermatitis  from  time  to  time  until  the  skin 
becomes  less  sensitive  as  the  patient  grows  older.  It  is  a  very 
easy  matter  to  hook  up  the  navel  with  a  tenaculum  in  such  a  case, 
and  to  excise  the  little  button  of  tissue  which  contains  micro- 
scopic remains  of  the  vitelline  duct. 


MALIGNANT     ISLANDS     AT     THE     NAVEL,    OCCURRING 

SIMULTANEOUSLY    WITH    MALIGNANT    DISEASE 

OF  THE  ABDOMINAL  OR  PELVIC  ORGANS. 

When  malignant  disease  is  present  in  the  abdominal  or  pelvic 
organs,  the  navel  sometimes  becomes  involved  in  disease  of  the 
same  type.  I  have  obtained  notes  from  four  cases  of  this  sort,, 
and  in  two  cases  microscopic  remains  of  the  vitelline  duct  were 
found  in  abundance  in  the  involved  navels.     The  other  two  were 


Fig.  31. — Embryonic  remains  in  a  navel  which  was  elsewhere  carcinomatous. 


not  examined  with  reference  to  that  point,  as  my  attention  had 
not  at  that  time  been  attracted  to  the  subject.  In  these  cases  the 
secondary  malignant  disease  had  occurred  at  a  point  particularly 
rich  in  embryonic  cells,  and  this  may  have  some  bearing  on  Cohn- 

94 


Malir7iani  Islands  at  the  Navel. 


95 


helm's  theory  relative  to  the  development  of  tumors  from  latent 
embryonic  cells. 

The  causative  elements  of  sarcomatous  and  of  carcinomatous 
disease  situated  at  a  distance  from  the  navel,  apparently  found 
their  way  through  the  blood  current  to  the  navel  in  four  patients, 
and  the  navels  of  these  patients  became  infected  islands  of  dis- 
ease, similar  in  character  to  that  which  was  present  in  the  other 
structures  at  the  time. 

The  four  cases  were  as  follows  : 

Case  i. — A  woman,  seventy  years  of  age  ;  diagnosis  of  cancer  of  the 
pylorus.  Six  months  from  the  beginning  of  her  symptoms  the  patient 
began  to  have  pain  at  the  navel,  and  she  noticed  a  small  lump  there, 
which  became  very  hard,  and  about  as  large  as  a  chestnut,  bluish-red 
in  color,  and  with  a  smooth  superficial,  ulcerating  external  surface  that 


Fig.  32. — Adeno-carcinoma  of  navel  from  Case  i. 


discharged  a  little  straw-colored  serum..  I  removed  the  diseased  navel, 
and  found  that  it  was  not  in  contact  with  anything  but  normal  struc- 
tures. The  patient  died  two  months  later  with  ordinary  symptoms  of 
cancer  of  the  pylorus,  but  a  necropsy  was  not  permitted.  The  disease 
at  the  navel  was  adeno-carcinoma,  evidently  developing  from  embryonic 
gland  tissue. 


96 


A'o/c's. 


Case  2. — A  man,  fifty-four  years  of  age  ;  carcinoma  of  the  glands 
of  the  left  groin  for  two  years  ;  intra-abdominal  symptoms  of  malignant 
disease.  For  four  weeks  a  small,  fungating  mass,  which  was  the  seat 
of  much  pain,  had  been  developing  at  the  navel.  The  navel,  as  a 
whole,  was  not  enlarged  or  hardened  in  this  case,  but  from  its  centre 
sprang  a  tuft  of  purplish-red  granulations  about  as  large  as  a  small  pea. 
I  removed  the  navel,  and  at  the  same  time  made  an  exploratory  opening 


Fig.  33. — Adeno-carcinoma  of  navel  from  Case  2. 

for  an  examination  of  the  abdomen.  The  omentum  was  the  seat  of 
colloid  carcinoma,  but  there  were  no  adhesions  of  omentum  to  furnish 
a  route  for  infection  to  the  navel.  The  disease  of  the  navel  was  adeno- 
carcinoma, and  the  specimen  contained  numerous  minute  dots  of 
intestinal  gland  tissue. 

Case  3. — Extract  from  a  letter  from  Dr.  Grinnell,  of  Burlington, 
Vermont :  "  Patient,  a  male,  sixty-eight  years  of  age  ;  diagnosis  of  cancer 
of  the  pylorus.  Eight  months  before  the  patient's  death,  the  navel  be- 
came hard  and  painful,  and  the  discharge  from  it  was  malodorous. 
Five  months  later,  the  liver  began  to  enlarge,  and  death  was  caused  by 
cancer  of  the  liver,  as  determined  at  necropsy.  The  disease  at  the 
navel  had  remained  confined  to  that  point,  while  the  disease  elsewhere 
made  progress." 


Malignant  Islands  at  the  Navel.  gy 

Case  4. — Extract  from  an  article  by  Dr.  Daniel  Lewis,  in  the  Hew 
York  Medical  /Record,  October  12,  18S9  :  "The  patient  was  suffering 
from  a  disease  of  the  fundus  of  the  uterus,  diagnosticated  as  sarcoma. 
While  this  was  in  progress  malignant  disease  attacked  an  umbilical 
hernial  sac,  evidently  beginning  at  the  navel  and  extending  from  there 
to  the  tissues  of  the  sac.  Examination  of  the  navel  showed  it  to  be  the 
seat  of  remains  of  the  vitelline  duct.  Section  of  one  part  of  the 
neoma  showed  large,  round-cell  alveolar  sarcoma,  and  the  deeper  sec- 
tion showed  a  mixture  of  round  and  spindle  cells." 


A  LAST  RESORT  HERNIA  OPERATION. 

A  DOG  pulled  out  some  of  the  sutures  which  I  had  placed  in 
his  abdominal  wall  after  an  experimental  operation,  and  part  of  a 
loop  of  bowel  descended  into  the  wound  during  the  night.  This 
loop  of  bowel  seemed  to  be  adherent  to  the  wound  margins,  and 
it  was  allowed  to  remain  undisturbed  for  observation.  Healing 
took  place,  and  there  seemed  to  be  no  further  progress  of  hernia. 
The  dog  was  not  disturbed  by  the  fixed  bowel.  It  seemed  proba- 
ble that  fixation  of  bowel  at  a  hernial  opening  could  be  utilized 
as  a  surgical  resource  in  some  few  cases  of  hernia  in  which  other 
and  simpler  resources  had  failed.  I  tried  further  experiments  on 
rabbits,  suturing  various  portions  of  bowel  to  the  margins  of  arti- 
ficial hernial  openings,  and  found  that  the  animals  did  not  suffer 
any  inconvenience.  There  has  been  no  opportunity  as  yet  to 
apply  this  resource  in  a  femoral  or  inguinal  hernia,  but  I  have  em- 
ployed it  in  one  large  umbilical  hernia  and  in  five  appendicitis 
cases  to  prevent  the  progress  of  ventral  hernias  after  large  drained 
wounds. 

In  none  of  these  cases  has  hernia  appeared  as  yet,  the  cases  dating 
back  twenty-four  months,  twenty-four  months,  twenty-two  months, 
twenty  months,  eighteen  months,  and  three  months,  respectively. 
The  distal  end  of  the  cecum  is  the  best  part  of  the  bowel  to  make 
fast  at  an  opening  in  the  right  inguinal  region,  because  it  is  less 
likely  to  kink  as  a  result  of  peristaltic  movements  than  any  other 
part  of  the  bowel.  The  danger  from  kinking  or  twisting  from  fixed 
bowel  is  real,  but  not  great,  if  we  are  to  judge  from  numerous 
cases  in  which  intestine  is  adherent  in  large  hernial  sacs,  and  as  a 
result  of  various  acute  inflammatory  processes  in  the  abdomen 
and  pelvis  which  leave  strong  adhesions  behind  ;  nevertheless  the 
resource  in  question  is  not  adapted  to  any  of  the  ordinary  curable 
cases  of  hernia  while  so  many  operations,  practically  free  from 
danger,  are  at  our  service. 

The  technique  of  the  operation  for  fixation  of  bowel  at  a 
hernial  opening,  consists  in  suturing  the  bowel  to  the  margins  of 
the   opening  with    sutures    carried    through    the    peritoneal  and 


A  Last  Resort  Her7iia  Operation, 


99 


muscular  coats  of  the  bowel.  The  parietal  peritoneum  is  first 
stripped  away  from  the  abdominal  wall  for  a  short  distance,  so 
that  bowel  peritoneum  unites  with  connective  tissue  of  the 
abdominal  wall    only,    otherwise    the    approximated    surfaces  of 


Fig.  34. — Segment  of  bowel  united  to  margins  of  hernial  opening  (Rabbit). 

A.  Stick  of  wood  inserted  to  show  lumen  of  intestine. 

B.  Skin  and  muscles. 

C.  Peritoneum. 

D.  Segment  of  attached  intestine.      Longitudinal  ridge  marks 

site  of  mesentery. 


peritoneum  would  be  apt  to  advance  conjointly  at  the  weak  spot. 
The  mechanical  effect  of  fixed  bowel  is  to  shunt  loops  of  movable 
bowel  away  from  the  weak  spot,  and  against  solid  walls  on  either 
side. 


THE    EXPERIMENTAL    PRODUCTION   OF    ILEAL   INTUS- 
SUSCEPTION WITH   CARBONATE  OF   SODIUM. 

At  an  abdominal  operation  in  which  normal  peristalsis  is 
retarded,  it  is  sometimes  difficult  to  know  in  which  direction  the 
bowel  runs,  and  various  substances  have  been  employed  for  ex- 
citing a  quick  peristalsis,  either  normal  or  reversed.  In  the 
hands  of  Dr.  Senn  a  satisfactory  reversed  peristalsis  has  been 
obtained  by  touching  the  peritoneal  surface  of  the  bowel  with 
chloride  of  sodium,  but  recently  a  note  went  the  rounds  of  the 
medical  press,  to  the  effect  that  sodium  carbonate  was  still  more 
eflficient.  In  order  to  test  the  efficacy  of  this  resource,  I  experi- 
mented upon  rabbits,  and  found  that  a  trifle  of  carbonate  of 
sodium  touched  to  the  ileum  of  rabbits  would  produce  intussus- 
ception in  a  few  seconds.  The  danger  of  the  production  of  the 
same  effect  in  the  ileum  of  man  is  so  great,  that  proof  of  the 
harmlessness  of  sodium  carbonate  must  be  furnished  before  we 
can  employ  it  for  exciting  reversed  peristalsis  at  an  abdominal 
operation. 

The  production  of  ileal  intussusception  in  a  rabbit  gives  a  very 
pretty  demonstration  of  the  mechanism  of  that  form  of  intussus- 
ception if  one  wishes  to  employ  it  for  teaching  purposes.  The 
rabbit  having  been  chloroformed,  an  incision  is  made  in  the 
abdominal  wall,  and  the  loop  of  ileum  is  brought  out.  If  the 
barometric  pressure  happens  to  be  high  at  the  time,  it  is  well  to 
rest  the  loop  of  bowel  on  moistened  cloth  or  paper  to  prevent 
too  rapid  drying  of  the  peritoneum  of  the  loop.  If  a  fraction  of 
a  grain  of  powdered  sodium  carbonate  is  then  touched  to  the 
peritoneal  surface  of  the  loop  of  ileum,  it  will  be  observed  that  in 
twenty  or  thirty  seconds  the  circular  fibres  of  the  bowel  at  that 
point  suddenly  contract  in  tonic  spasm  ;  peristaltic  movements  of 
the  longitudinal  fibres  of  neighboring  bowel  then  cause  a  slowly 
progressing  engulfing  of  the  portion  of  bowel  which  is  in  a  state 
of  spasm,  and  the  ascending  intussusception  thus  continues  until 
the  mass  of  engulfed  mesentery  becomes  so  large  as  to  block 
further  progress.     An    intussusception   of    about   two    inches   of 

lOO 


Experimental  Ileal  Inlusstisception. 


lOI 


bowel  can  often  be  obtained  in  five  or  six  minutes,  and  it  would, 
without  doubt,  remain  permanently  in  this  position,  subject  to 
inflammatory  complications,  but  I  have  not  allowed  any  rabbits  to 
live  in  order  to  determine  that  point. 

The  mechanism  of  intussusception  produced  by  the  influence 
of  sodium  carbonate  is  the  reverse  of  that  which  occurs  as  a  post- 
mortem phenomenon,  as  I  observed  the  latter  in  one  case.  In 
that  case,  a  wave  of  peristalsis  of  the  circular  fibres  of  the  segment 
of  bowel  formed  a  wide,  lax  intussuscipiens,  into  which  the  neigh- 


FiG.  35. — A  few  particles  of  carbonate 
of  sodium  placed  upon  ileum  of  rabbit. 


Fig.    36. — Spasm  of  circular  fibres   of 
bowel  at  site  of  sodium  carbonate. 


Fig.  37. — Intussusception  of  contracted  portion  of  bowel. 


boring  segment  of  bowel  was  easily  pushed  for  a  distance  of  a 
few  lines  by  normal  peristaltic  progression.  Waves  of  peristalsis 
of  the  circular  muscular  coats  seemed  to  sweep  along  the  ileum, 
and  several  intussusceptions  were  on  the  point  of  forming.  It  is 
not  unlikely  that  a  few  of  the  cases  of  intussusception  in  children 
may  occur  as  a  result  of  spasm  of  a  portion  of  the  bo\fel  similar 
to  the  sodium-carbonate  contraction,  and  caused  by  the  toxines 
absorbed  from  the  lumen  of  the  intestine.  We  know  that  spasm 
of  other  muscles,  manifested  in  the  form  of  convulsions,  very 
frequently  arises  from  that  cause  in  children  whose  intestinal  con- 
tents ferment. 


THE   REASON  WHY  PATIENTS   RECOVER  FROM   TUBER- 
CULOSIS OF  THE  PERITONEUM. 

We  have  recently  learned  that  patients  suffering  from  tuberculosis 
of  the  peritoneum  commonly  make  an  excellent  and  rapid  recovery 
when  the  peritoneal  cavity  has  been  exposed  through  an  abdominal  in- 
cision. In  rare  instances  patients  also  begin  to  suddenly  recover  spon- 
taneously from  tuberculosis  of  the  peritoneum.  When  tuberculosis 
comes  to  a  stop  we  presume  that  the  tubercle  bacilli  have  been  killed, 
and  there  has  been  much  speculation  as  to  what  could  bring  about  that 
end  in  a  class  of  cases  in  which  infection  was  so  diffuse  as  it  usually  is 
in  the  peritoneum.  The  following  experiments  were  tried  for  the  pur- 
pose of  gaining  a  clew  to  the  agent  which  proves  fatal  to  the  bacilli. 

I  removed  several  ounces  of  fluid  from  the  abdominal  cavity  in  a 
typical  case  of  peritoneal  tuberculosis,  and  exposed  the  fluid  to  the  air 
for  twenty-four  hours.  It  was  then  placed  in  an  incubator  for  forty-eight 
hours,  and  kept  at  a  temperature  of  about  ioo°  F.  At  the  end  of  that 
time  the  fluid  was  swarming  with  saprophytes,  and  the  toxines  which 
they  had  produced  were  then  separated  from  it.  Small  portions  of  the 
toxines  proved  immediately  fatal  to  virulent  test-tube  cultures  of  tu- 
bercle bacilli,  but  it  was  thought  best  to  subject  these  cultures  to  a 
further  test  for  determining  if  they  were  capable  of  further  develop- 
ment. Numbers  i,  2,  3,  4,  5,  6,  7,  and  8  are  used  to  designate  the  rab- 
bits on  which  control  experiments  were  made.  Suspensions  i  and  2 
are  suspensions  of  tubercle  bacilli  in  bouillon  ;  suspensions  3  and  4 
represent  suspension  of  tubercle  bacilli  in  the  ptomaine. 

jl^uly  27,  1894. — No.  I  was  inoculated  in  the  eye  with  a  pure  culture 
of  tubercle  bacilli.  On  the  same  day  No.  2  was  inoculated  in  the  eye 
with  suspension  No.  i.  No.  3  was  inoculated  with  suspension  No.  2. 
These  suspensions  had  been  in  the  incubator  for  twenty-four  hours. 

yxily  28///. — Nos.  I  and  2  seemed  to  suffer  very  little,  but  No.  3  was 
quite  ill,  and  the  infected  eye  was  suppurating  ;  consequently  suspen- 
sion No.  2  was  not  used  again  in  tlie  eye,  but  was  injected  under  the 
skin  of  the  abdomen.  No.  4  was  inoculated  in  the  eye  with  No.  i  sus- 
pension, which  had  been  in  the  incubator  for  forty-eight  hours.  No.  5 
•was  inoculated  on  the  abdomen  with  suspension  No.  2,  which  had  also 
been  in  the  incubator  for  forty-eight  hours. 

102 


TubercMlosis  of  Peritoneum.  103 

fuly  2y^th. — Nos.  6  and  7  were  inoculated  like  Nos.  4  and  5,  respec- 
tively. Suspensions  had  been  in  the  incubator  for  four  days.  As  No.  i 
control  animal  showed  no  specific  effect  from  the  inoculation  with  the 
pure  culture,  and  only  a  small  quantity  of  the  fluid  remained,  the  ex- 
periments were  stopped  to  await  results,  and  to  obtain  another  culture 
of  tubercle  bacilli  in  case  this  culture  should  prove  sterile. 

August  Afth. — No.  3  died,  and  the  autopsy  showed  the  cause  of  death 
to  be  meningitis  ;  no  tuberculosis. 

August  10th. — No.  I  died.  The  autopsy  showed  the  cause  of  death 
to  be  coccidium  ;  no  tuberculosis.  No.  6  also  died  of  coccidium  ;  no 
tuberculosis. 

August  -^ist. — Another  culture  of  tubercle  bacilli  was  used,  and  sus- 
pensions 3  and  4  made  like  suspensions  i  and  2,  respectively.  No.  8 
Avas  inoculated  on  the  abdomen  with  the  new  culture  of  tubercle 
bacilli. 

September  2d. — No.  2  was  inoculated  for  the  second  time,  but  with 
suspension  No.  3,  and  No.  7  was  inoculated  with  suspension  No.  4. 
These  suspensions  had  been  in  the  incubator  for  forty  hours. 

Septetnber  ^th. — No.  4  was  inoculated  with  suspension  No.  3,  and  No. 
5  was  inoculated  with  suspension  No.  4.  These  suspensions  had  been 
in  the  incubator  for  four  days. 

September  24///. — Nos.  4  and  5  were  killed,  and  at  the  site  of  inocula- 
tion, as  well  as  in  the  lungs,  numerous  submiliary  tubercles  were  found. 
The  three  remaining  animals  show  signs  of  tuberculosis,  but  have  not 
yet  been  killed.  Nos.  3  and  4,  however,  showed  that  the  toxines  in 
which  that  lot  of  bacilli  was  suspended  did  not  render  the  bacilli 
sterile. 

It  is  apparent,  then,  that  when  the  abdominal  cavity  is  opened  and 
drained,  saprophytes  which  enter  through  the  drainage  opening  produce 
toxines,  which  are  fatal  to,  or  which  inhibit  the  growth  of  certain  tubercle 
bacilli.  In  some  cases  the  bacilli  are  not  killed  by  the  toxines,  but  their 
growth  is  probably  inhibited  for  a  sufficient  length  of  time  so  that 
nuclein  brought  by  the  polynuclear  leucocytes  in  the  peritoneum  can 
destroy  them.  This  seems  like  a  rational  explanation  for  the  reason 
why  patients  recover  from  tuberculosis  of  the  peritoneum  after  opera- 
tion ;  but  on  this  theory  the  abdomen  should  not  be  closed  imme- 
diately, but  should  be  drained  in  order  to  allow  the  saprophytes  to 
enter  through  the  drainage  opening.  A  case  of  tuberculosis  of  the 
peritoneum  could  suddenly  begin  to  recover  spontaneously,  without 
operation,  if  saprophytes  were  to  enter  the  abdominal  cavity  through  a 
Fallopian  lube.  The  reasoa  why  saprophyte  toxines  can  produce  such 
an  immediate  and  widespread  effect  upon  tubercle  bacilli  in  the  peri- 
toneal cavity  is  because  of  the  character  of  the  lymphatic  circulation  of 


1 04  Notes. 

the  peritoneum,  such  toxines  being  carried  quickly  to  all  parts  of  the 
peritoneum,  and  the  polynuclear  leucocytes  which  go  to  the  help  of  the 
patient  have  very  free  access  to  all  of  the  involved  parts.  In  the  lung,. 
or  in  the  knee-joint,  we  have  no  such  favorable  arrangement  of  lym- 
phatics and  capillaries,  and  consequently  saprophyte  toxines  cannot 
reach  all  of  the  involved  structures  in  which  tubercle  bacilli  are  grow- 
ing. In  some  cases  of  peritoneal  tuberculosis  a  change  for  the  better 
occurs  in  the  case  almost  immediately — sometimes  within  seventy-two 
hours,  in  cases  in  which  intestines  are  firmly  glued  together,  the  lym- 
phatic circulation  being  sufficient  to  carry  toxines  through  any  adher- 
ent structures.  In  cases  in  which  the  peritoneal  surfaces  have  been 
found  to  be  firmly  united,  and  masses  of  miliary  tubercle  were  abun- 
dant in  the  abdominal  cavity,  a  glistening  peritoneum,  free  from 
adhesions,  has  been  found  on  subsequent  operation,  or  on  necropsy 
years  afterward. 


THE  PREVENTION  OF  SECONDARY  PERITONEAL  ADHE- 
SIONS BY  MEANS  OF  AN  ARISTOL  FILM. 

When  adherent  peritoneal  surfaces  have  been  separated  from 
each  other  by  surgeons,  there  is  danger  of  secondary  adhesion 
as  soon  as  the  surfaces  which  are  bare  of  serosa  have  fallen 
together  again,  and  various  resources  have  been  employed  for 
preventing  such  adherence.  I  observed  that  if  a  layer  of  aristol 
were  interposed  between  the  margins  of  the  wound,  it  would 
sometimes  present  a  mechanical  obstacle  to  primary  union,  and  it 
seemed  probable  that  if  aristol  were  applied  to  peritoneal  adhesion 
surfaces,  it  would  form  a  film  with  lymph,  and  that  this  aristol 
film  would  offer  an  obstacle  to  secondary  adhesion,  and  give  the 
raw  surfaces  an  opportunity  to  heal  separately. 

A  rabbit  was  anesthetized,  and  two  inches  of  two  intestinal 
loops  were  lightly  scratched  with  a  needle,  and  sutured  together. 
One  inch  of  each  of  the  opposed  surfaces  was  covered  with  a  thin 
layer  of  aristol,  and  the  other  inch  was  left  without  protection. 
At  the  end  of  a  week  the  rabbit  was  again  examined,  and  it  was 
found  that  the  aristol-covered  surfaces  were  adherent,  but  with 
such  a  succulent-looking  mass  of  lymph  that  it  was  deemed 
advisable  to  experiment  with  other  rabbits,  and  allow  time  for 
complete  absorption  of  plastic  exudate.  Three  more  rabbits  were 
treated  like  the  first  one,  but  with  deeper  scarification  of  the  peri- 
toneum. Loops  of  ileum  were  approximated  in  one,  and  loops 
of  colon  in  the  other  two.  The  rabbit  with  sutured  ileum  died 
of  intestinal  obstruction  a  few  days  later  ;  the  other  two  were 
killed  at  the  expiration  of  five  weeks.  In  one  there  were  close, 
dense  adhesions  at  the  parts  that  had  been  scarified  and  approxi- 
mated without  aristol  protection,  and  adhesion  only  at  suture 
punctures  in  the  aristol-protected  segments.  Elsewhere  over  the 
aristol-protected  segments  there  were  no  adhesions,  but  the  aristol 
remained  encapsulated  in  the  new  serosa.  In  the  other  rabbit  there 
were  loose  filamentous  adhesions  between  the  unprotected  sur- 
faces, and  none  at  all  where  aristol  had  kept  the  surfaces  apart. 
In  the  second  rabbit,   as  in   the   first  one,  the  aristol   remained 


1 06  Notes. 

encapsulated  in  the  new  serosa.  What  becomes  of  the  encapsu- 
lated aristol  eventualh',  I  do  not  know.  It  is  not  soluble  in  blood 
serum,  but  it  is  soluble  in  fat,  and  it  is  quite  possible  that  fatt}- 
metamorphosis  of  surrounding  tissues  may  in  some  places  cause 
its  slow  solution  and  absorption.  The  experiments  in  rabbits 
were  severe  ones  because  the  wounded  peritoneal  surfaces  were 
held  actually  in  apposition  by  sutures.  In  practice,  the  peristaltic 
movements  of  the  intestines,  and  the  shifting  of  movable  viscera 
aid  us  in  our  efforts  to  keep  aristol-protected  surfaces  apart. 

Since  the  date  of  the  preliminary  experiments,  I  have  had 
several  opportunities  for  observation  of  the  value  of  this  resource 
in  cases  which  were  subjected  to  further  operative  procedures 
some  months  or  years  after  adhesions  had  been  prevented  from 
re-forming.  We  cannot  obtain  an  aristol  film  on  deeply  seated 
adhesion  surfaces  if  blood  serum  or  peritoneal  fluid  wash  away 
the  aristol  before  it  has  become  fixed  with  lymph,  but  as  half  a 
minute  will  answer  for  this  purpose — a  minute  is  better, — the  film 
can  be  formed  on  surfaces  which  can  be  well  dried  with  a  sponge 
or  gauze,  and  exposed  to  the  air  for  that  length  of  time.  The 
pedicle  of  an  ovarian  tumor,  or  any  tissue  bared  of  peritoneum, 
will  not  form  troublesome  adhesion  to  the  bowel  if  protection  is 
given  by  forming  a  lymph-aristol  film  upon  such  raw  surfaces. 


ANOTHER    METHOD   FOR   PALPATION   OF   THE   KIDNEY. 

Israel  finds  a  kidney  by  placing  the  patient  upon  her  back  with 
■flexed  legs,  and  then  while  one  hand  makes  pressure  over  the 
lumbar  region  of  the  patient,  the  tips  of  the  outstretched  fingers 
of  the  examiner's  other  hand  are  placed  just  below  the  costal 
cartilages,  and  on  a  line  which  runs  from  the  middle  of  Poupart's 
ligament  parallel  with  the  median  line  of  the  abdomen.  Then, 
with  each  expiratory  movement  on  the  part  of  the  patient,  the 
fingers  are  pressed  deeper  and  deeper  down  toward  the  kidney, 
and  the  impression  left  upon  the  finger  tips  at  each  step  of  prog- 
ress is  kept  w^ell  in  mind.  When  the  lower  end  of  the  kidney  is 
felt,  the  patient  is  instructed  to  take  a  deep  breath,  and  force  the 
kidney  out  under  the  fingers  of  the  examiner.  Guyon  palpates 
in  very  much  the  same  way,  but  introduces  a  new  feature,  which 
consists  in  making  quick,  forcible  pressure  with  the  fingers  in  the 
lumbar  region,  thereby  causing  a  spasmodic  contraction  of  the 
quadratus  lumborum  muscle,  w^iich  lifts  the  kidney  up  toward  the 
•examining  hand.  When  the  patient  is  in  a  supine  position,  there 
is  sometimes  an  obstacle  to  good  palpation  of  the  kidney  in  the 
presence  of  interposed  omentum  and  intestine  or  stomach.  A 
lobe  of  liver  will  sometimes  be  forced  under  the  finger,  and  simu- 
late kidney  very  closely  unless  one  is  careful  to  first  make  out  the 
sharp  edge  of  the  liver,  and  then  be  sure  that  the  fingers  are  well 
iinder  it. 

In  placing  patients  in  various  positions  for  the  purpose  of  ex- 
amining loose  kidneys,  I  have  found  one  position  that  is  often 
very  satisfactory.  If  the  right  kidney  is  to  be  palpated,  the 
patient  lies  upon  her  left  side  wnth  the  legs  flexed  so  that  the 
abdominal  muscles  are  relaxed,  and  the  intestines  and  omentum 
sag  toward  the  table  side  of  the  patient.  If  the  kidney  is  loose, 
it  then  slides  out  in  such  a  way  that  it  becomes  the  highest  round 
body  found  beneath  the  abdominal  wall  at  a  certain  point.  The 
intestines  and  omentum  are  out  of  the  w^ay,  and  the  kidney  has 
moved  between  peritoneal  planes,  or  has  swung  upon  a  meso- 
nephron   into   a   position   to   be   easih'   examined.     The    certain 


1 08 "  Notes. 

point  at  ^vhich  the  kidney  is  found  is  somewhere  in  the  cavity 
that  forms  along  the  margin  of  the  right  quadratus  lumborum. 
muscle  when  the  abdominal  viscera  sag  towards  the  table.  Dif- 
ferent patients  require  somewhat  different  positions  of  the  limbs, 
and  different  angles  with  the  top  of  the  examining  table,  in  order 
that  the  point  of  greatest  degree  of  relaxation  of  the  abdominal 
wall  be  obtained.  A  very  fleshy  patient,  for  instance,  may  have 
to  be  rolled  almost  into  a  prone  position  because  the  weight  of  the 
viscera  must  be  partly  borne  by  the  table  before  the  tension  of 
the  abdominal  wall  is  relieved.  If  a  loose  kidney  does  not  at  once 
slide  out  of  the  normal  position  when  the  patient  is  properly- 
placed,  a  blow  upon  the  lumbar  region  with  the  hand  will  displace 
it,  and  we  can  then  obtain  a  more  resonant  percussion  note  over 
the  site  that  the  kidney  formerly  occupied.  With  some  patients 
in  the  position  described  I  have  been  enabled  to  hold  the  entire 
kidney  in  one  hand  almost  as  easily  as  if  it  were  a  potato  in  a  bag. 

For  examining  kidneys  that  are  not  loose,  I  still  prefer  to  ex- 
amine according  to  the  method  of  Israel,  or  of  Guyon.  A  great 
many  patients  who  are  at  present  being  treated  for  obscure  dis- 
ease of  the  pelvic  organs,  and  for  all  sorts  of  abdominal  distress, 
will  be  found  to  have  a  loose  kidney,  if  a  satisfactory  method  for 
palpation  of  the  kidney  is  employed.  The  real  proportion  of 
loose  kidneys  is  not  determined  in  ordinary  post-mortem  exami- 
nations because  a  kidney  which  would  slip  between  the  peri- 
toneal planes  almost  to  the  pelvis,  may  glide  back  into  place  and 
become  fixed  by  rigor  mortis,  or  remain  in  place  simply  by  its 
own  weight,  with   the  subject   in  the  recumbent  position. 

True  floating  kidney  with  a  meso-nephron  is  of  rare  occurrence, 
but  loose  kidneys  are  very  common.  The  right  kidney  is  the 
one  that  usually  wanders,  presumably  because  corsets  which  fix 
the  lower  costal  border  prevent  the  liver  from  gliding  forward  on. 
inspiration,  and  the  liver  then  must  move  up  and  down  like  a 
piston,  forcing  the  kidney  away  from  its  connective-tissue  bed.  A 
retroverted  uterus  may  sometimes  cause  enough  tension  of  the 
short  right  ureter  to  start  a  kidney  out  of  its  bed.  There  are 
many  common  causes  for  a  kidney  leaving  its  connective-tissue 
anchorage,  and  once  it  is  loosened,  gravitation  increases  the  range' 
of  the  wandering. 

Some  years  ago  I  prophesied  that  loose  kidneys  would  form  the 
next  subject  for  general  widespread  interest  in  the  medical  pro- 
fession, but  appendicitis  and  anti-toxines  have  come  forward  first. 


EXPERIMENTS  GERMANE  TO  THE  SUBJECT  OF  ABDOMI- 
NAL SUPPORTERS  AFTEPv.  LAPAROTOMY. 

An  abdominal  incision  about  two  inches  in  lengtli  was  made  in  the 
middle  abdominal  line  in  a  series  of  adult  rabbits,  and  the  incision  was 
■closed  with  catgut  in  two  tiers.  The  first  tier  included  peritoneum, 
■muscle,  and  fibrous  planes  ;  the  second  tier  included  skin.  The  method 
of  examining  the  character  of  repaired  tissues  afterward,  consisted  in 
■dividing  up  the  abdominal  walls  into  strips,  half  an  inch  wide,  cut 
transversely  across  the  abdomen  after  the  rabbits  had  been  killed  with 
chloroform.  The  strips  were  then  dissected  in  such  a  way  that  skin 
was  separated  from  muscles  and  muscles  from  peritoneum.  It  was  not 
possible  to  separate  the  peritoneum  nicely  in  rabbits  because  of  its 
close  connection  with  the  abdominal  wall.  The  fresh  strips  were  kept 
in  saline  solution  while  the  experiments  were  being  made.  The  testing 
apparatus  consisted  of  a  pair  of  screw  clamps  and  a  spring  balance 
registering  pounds  up  to  fifty.  One  end  of  the  strip  of  tissue  was  fas- 
tened between  blocks  of  wood  to  prevent  slipping,  and  the  clamps  were 
then  screwed  down  upon  it.  The  other  end  being  treated  in  the  same 
way,  the  spring  balance  was  hooked  to  one  clamp,  and  traction  was 
made  on  the  other,  while  the  indicator  was  watched. 

First  rabbit — three  days  after  operation.  A  strip  of  unwounded  ab- 
dominal wall,  half  an  inch  wide  and  three  inches  long,  was  first  tested. 
The  skin  pulled  apart  with  a  traction  of  eighteen  pounds.  (In  all  of 
these  experiments  the  pounds  are  given  in  round  numbers.)  The  strip 
of  muscle  and  fascia  pulled  apart  at  sixteen  pounds  ;  the  peritoneum 
containing  a  little  muscular  tissue  from  the  abdominal  wall,  at  seven 
pounds. 

Sutured  structures  removed — no  tissue  bore  a  pull  of  one  pound. 

Second  rabbit — killed  seven  days  after  operatioii.  The  peritoneum 
was  injured  in  trying  to  dissect  it  away  for  experiment. 

Third  rabbit — killed  seven  days  after  operation.  The  peritoneum 
could  be  dissected  away  fairly  well  by  first  pinching  it  up  between  the 
fingers,  but  some  muscuhr  fibres  remained  attached.  All  sutures 
removed. 

Normal  peritoneum  tore  at  eight  pounds. 

Sutured  peritoneum  tore  at  eight  pounds. 

Normal  muscle  wall  tore  at  fourteen  pounds. 

log 


1 1  o  Notes. 

Suurcd  line  in  muscle  wall  tore  at  five  pounds. 

aS'ornial  skin  tore  at  seventeen  pounds. 

Sutured  skin  tore  at  two  pounds. 

Fourth  rabbit,  killed  ten  days  after  operation. 

The  peritoneum  was  not  tested  as  it  was  evidently  perfectly  repaired. 

The  muscle  gave  way  at  stitch  holes,  but  the  tear  extended  into  nor- 
mal muscle,  as  well  as  into  wound  line. 

The  skin  tore  through  wound  line. 

Fifth  rabbit,  killed  fourteen  days  after  operation. 

The  sutured  peritoneum  was  normal. 

Muscle  and  fibrous  structures  did  not  tear  along  the  wound  line  more 
readily  than  in  normal  tissue.  The  fibres  slid  apart,  as  threads  slide  in 
woven  material  which  is  subject  to  tension,  in  normal  tissues  and  in  the 
vicinity  of  the  wound  alike. 

The  skin  gave  way  in  the  wound  line  still,  but  sliding  of  the  fibres 
instead  of  direct  tearing  began  at  this  date. 

Sixth  rabbit,  killed  eighteen  days  after  operation. 

Ail  repaired  structures  were  found  to  be  as  strong  as  normal  ones, 
but  the  tears  beginning  anywhere  near  the  wound  line  always  ran  to  a 
stitch  depression,  or  else  began  there  and  ran  to  near  tissues. 

Seventh  rabbit,  killed  at  iiventy-one  days. 

Fighth  rabbit,  killed  at  thirty-eight  days. 

The  same  observations  were  made  on  these  as  in  the  sixth  rabbit. 

///  practice  I  have  not  to  my  knowledge  had  ventral  hernia  follow 
operation  in  wounds  which  were  closed  at  the  time  of  operation  with  or 
without  a  drain.  This  includes  several  hundred  laparotomies  for  all  sorts 
of  conditions  requiring  abdominal  operation.  The  only  patients  whom 
I  know  to  be  wearing  abdominal  supporters  to-day  are  two  who  had 
general  suppurative  peritonitis  and  whose  wounds  had  to  be  left  widely 
opened,  one  who  came  into  my  hands  as  a  ventral  hernia  case,  and 
a  fourth  whose  abdominal  wall  feels  weak  from  local  paralysis  of  mus- 
cles near  the  incision,  but  who  has  no  hernia.  If  any  other  patients  of 
mine  are  wearing  abdominal  supporters  or  trusses  of  any  sort  for  post- 
operative hernia  I  would  like  to  be  apprised  of  the  fact,  for  quotation 
in  a  later  edition.  As  a  rule,  patients  were  allowed  to  get  out  of  bed 
on  the  seventeenth  day  after  operation,  and  no  abdominal  supporters 
have  been  applied  afterward  excepting  in  the  four  cases  mentioned, 
although  a  common  abdominal  bandage  for  general  support  has  some- 
times been  kept  on  by  the  patients  for  a  short  time  after  getting  out  of 
bed.  Abdominal  supporters  seem  to  be  unnecessary  if  the  abdominal 
structures  have  been  well  sutured,  but  if  suturing  has  not  been  done 
accurately,  abdominal  supporters  I  believe  are  useless  for  the  prevention 
of  hernia.        I  have  always  made  it  a  rule  to  suture  structures  separately 


Repair  of  Abdomijial  Wall.  1 1  i 

and  with  the  utmost  degree  of  precision,  feeling  that  in  that  luay  oi.ly 
could  structures  be  left  as  iiiey  were  found.  Silk  or  silver  wire  have 
never  been  used  for  closing  my  abdominal  wounds. '  Silk-worm  gut 
was  employed  in  perhaps  twenty  cases.  Kangaroo  tendon  was  tried 
satisfactorily  in  a  few,  but  small  chromic  catgut  was  used  for  the  hun- 
dreds. Of  late  years  my  sutures  have  not  been  passed  through  the 
adipose  layer  of  abdominal  Avails,  as  the  fatty  layers  are  perfectly 
approximated  by  atmospheric  pressure  after  the  deeper  tissues  and 
skin  have  been  accurately  sutured  with  fine  catgut. 


AN  ADDITION  TO  McGUIRE'S  OPERATION  TOR  A  SUPRA- 
PUBIC URETHRA. 

Ix  only  one  case  has  there  been  occasion  to  try  the  following  re- 
source, because  patients  with  hypertrophy  of  the  prostate  gland  under 
careful  palliative  treatment  and  management  do  not  often  require 
surgical  operation. 


Fig.  38. — A.  Rectus  abdominis  muscles. 

B.  Skin  flaps  outlined. 

C.  Skin  flaps  dissected  from  attachments  and  turned  down. 

This  patient,  sixty  years  old,  could  not  be  relieved  by  the  resources 
which  were  faithfully  applied,  and  he  was  suffering  from  chronic  septi- 


Suprapzibic  Urethra. 


I  I 


cemia  from  an  aggravated  suppurative  cystitis.  He  could  not  pass  a 
catlieter  or  empty  the  bladder  completely  without  a  catheter.  His 
prostate  gland  was  large  and  irregularly  hypertrophied.  An  in- 
cision four  inches  long,  was  made  in  the  middle  abdominal  line,  end- 
ing at  the  pubes.  Then  an  incision  was  made  on  either  side  of  the 
mid-line  incision,  making  two  strips  of  skin  which  were  to  be  employed 
later  for  forming  a  supra-pubic  urethra.  The  bladder  was  brought 
up  to  the  opening  in  the  abdominal  wall,  and  held  temporarily  with 
sutures.  As  in  the  Hunter  McGuire  operation,  the  bladder  was  then 
opened  at  the  lowest  anterior  point.     The  strips  of  skin  together  with 


Fig.  39.— C.  Skin  flaps  turned 
in  and  sutured  to  bladder. 


Fig.  40. — Wound  closed  and 
hstula  formed. 


fat  and  subcutaneous  tissue  were  dissected  away  from  either  side  of 
the  mid-line  ir.cision,  leaving  them  attached  at  their  distal  ends.  These 
strips  were  about  one  third  of  an  inch  broad.  Their  free  ends  were 
sutured  with  fine  catgut  to  the  mucosa  of  the  bladder,  each  strip  on  its 
respective  side.  The  temporary  sutures  which  held  the  bladder 
against  the  abdominal  wall  were  cut,  and  when  the  bladder  dropped 
back,  it  took  with  it  the  two  ribbons  which  had  been  sutured  to  the 
mucosa  of  the  bladder  and  which  then  lay  face  to  face  with  the  cutane- 


1 1 4  Notes. 

ous  surfaces  in  apposition.  That  made  a  fistula  lined  with  skin,  reach- 
ing from  the  mucosa  of  the  bladder  to  the  skin  of  the  abdomen. 
Aristol  was  rubbed  into  the  wound  to  prevent  infiltration  of  urine,  and 
a  drainage  wick  with  one  end  in  the  bladder  and  the  other  at  the  ab- 
dominal surface  drained  off  urine  while  the  process  of  repair  was  going 
on.  Four  weeks  after  the  operation  the  wounds  had  entirely  healed. 
The  patient  could  then  hold  his  urine  for  three  hours,  and  pass  it  at 
will,  using  a  glass  tube  to  press  against  the  abdominal  wall  to  guide  the 
urine  away  from  his  clothing.  An  ordinary  expulsive  effort  was  suf- 
ficient to  empty  the  bladder  by  way  of  this  fistula,  and  no  urine  passed 
through  the  penis. 

One  year  after  the  operation  the  patient  could  still  hold  his  urine 
for  three  hours,  but  there  was  a  trifle  of  moisture  about  the  opening 
most  of  the  time.  Two  years  later,  there  was  a  still  greater  leakage  of 
urine,  although  the  patient  was  able  to  carry  on  all  of  his  work  as  a 
farmer.  The  reason  why  the  later  trouble  occurred  was  because  the 
walls  of  the  fistula  were  rather  rigid,  the  strips  of  skin  having  con- 
tracted to  form  a  firm,  round  canal.  In  another  and  similiar  operation, 
I  would  make  the  strips  more  than  half  an  inch  wide  in  order  to  ob- 
tain a  supra-pubic  urethra  with  walls  which  would  remain  soft  enough 
to  keep  them  in  apposition. 


THE  DRAINAGE  WICK. 

The  application  of  the  principle  of  capillary  drainage  for  wounds 
is  potent  for  good  if  applied  in  full  knowledge  of  the  mechanical 
features  of  this  resoiirce,  and  potent  for  evil  if  applied  wrongly. 
An  illustration  of  its  uselessness  is  observed  if  we  place  one  end 
of  the  strip  of  absorbent  gauze  in  the  uterus,  and  leave  the  other 
end  folded  up  in  the  vagina  ;  but  if  the  end  of  gauze  in  the  vagina 
is  brought  outside  and  allowed  to  rest  in  a  mass  of  absorbent 
gauze,  capillary  drainage  proceeds  usefully  and  at  once,  until  the 
mass  of  gauze  becomes  saturated  with  serum,  when  capillary 
power  again  decreases,  and  stops.  A  very  large  gauze  drain  or 
gauze  packing  in  the  abdominal  cavity  is  potent  or  impotent  rela- 
tively with  its  size  as  compared  with  that  of  a  mass  of  absorbent 
gauze  with  which  it  is  in  contact  upon  the  abdominal  wall.  The 
larger  the  mass  of  gauze  within  the  abdominal  cavity,  and  the 
smaller  the  mass  on  the  outer  wall,  the  less  effective  is  the  drain- 
age. A  large  mass  upon  the  outer  wall  ceases  action  when  it  be- 
comes saturated  with  fluid.  A  mass  of  gauze  within  the  abdomi- 
nal cavity  is  soon  filled  in  its  meshes  with  coagulated  lymph,  and 
its  capillary  action  ceases.  The  lymph  unites  gauze  and  tis- 
sues together  and  repair  begins,  Nature  attempting  to  encapsu- 
late the  gauze.  Then,  when  the  gauze  is  removed,  the  tissues 
are  rudely  disturbed,  and  the  excess  of  reparative  lymph  which 
has  been  thrown  out  makes  an  inviting  field  for  bacteria.  Repair 
cannot  proceed  until  the  excess  of  lymph  has  become  absorbed 
or  has  broken  down.  Gauze  is  rendered  still  less  useful  if  loaded 
with  iodoform  and  fixing  agents. 

In  order  to  obtain  the  full  benefit  of  capillary  gauze  drainage, 
and  employ  a  small  "  drawing  column  "  of  absorbent  gauze  for 
the  interior  of  the  wound,  a  large  "  receiving  mass  "  of  absorbent 
gauze  must  be  placed  in  contact  with  it,  lying  outside  of  the 
wound.  The  mass  of  receiving  gauze  must  be  changed  when  it 
becomes  saturated  to  the  point  of  decreased  power,  otherwise  it 
will  have  little  mechanical  effect  upon  the  column  of  drawing 
gauze  within.    Reparative  lymph  is  prevented  from  encapsulating 


1 1 6  JVoks. 

the  drawing  column  of  gauze,  which  I  call  "  the  A\ick,"  by  sur- 
rounding it  with  gutta-percha  tissue  or  Lister's  protective  oiled 
silk.  This  also  prevents  disturbance  of  the  tissues  when  the  wick 
is  removed,  as  union  does  not  take  place  between  the  tissues  and 
the  waterproof  material.  The  wick  is  made  of  a  strip  of  absorb- 
ent gauze  not  much  larger  round  than  a  lead-pencil  for  most  pur- 
poses, and  this  strip  of  gauze  is  rolled  in  gutta-percha  tissue  very 
much  as  one  w^ould  roll  a  cigarette.  Such  a  wick  could  draw^  quarts 
of  serum  or  blood  out  of  the  abdominal  cavity,  and  it  forces  op- 
posed peritoneal  planes  at  a  distance  to  act  by  capillarity  from 
all  parts  of  the  abdominal  cavity  toward  the  point  at  which  the 
greatest  capillary  power  is  being  exerted.  Little  holes  are  snipped 
through  the  gutta-percha  covering  of  the  wick  after  it  has  been 
rolled,  so  that  the  fluids  can   enter  at  more  than  one  point,  but 


Fig.  41. — Drainage  wick. 

the  holes  are  not  large  enough  to  allow  tissues  to  become  adher- 
ent to  the  gauze  within  the  waterproof  material.  The  wick  is  not 
used  for  more  than  thirty  hours,  as  a  rule,  in  the  abdominal  cavity, 
for  adhesions  may  be  expected  to  Avail  off  any  sort  of  drainage 
apparatus  in  the  peritoneal  cavity  by  the  end  of  that  time.  If 
further  drainage  is  necessary,  I  carry  a  narrow  strip  of  gutta- 
percha tissue  into  the  wound,  and  then  allow  the  pressure  of  the 
tissues  to  force  fluids  along  the  line  of  least  resistance,  which  is 
along  the  strip  of  gutta-percha  tissue.  The  gauze  in  the  wick 
must  be  rolled  loosely.  A  wick  long  enough  to  rest  behind  the 
uterus  will  adjust  itself  to  curves  so  nicely,  and  will  be  so  soft, 
that  no  shock  is  caused  by  its  presence.  After  removing  the 
drainage  wnck  from  a  wound,  balsam  of  Peru  is  generally  injected 
into  the  sinus  for  a  few  days,  and  a  final  injection  of  iodoform  and 
glycerine  in  the  proportion  of  one  part  to  seven  is  very  efificient. 


ENDOSCOPIC  TUBES   FOR    DIRECT    INSPECTION  OF  THE 
INTERIOR  OF  THE  BLADDER  AND  UTERUS. 

For  direct  inspection  of  the  interior  of  the  uterus  in  women, 
and  of  the  urinary  bladder  in  both  sexes,  I  use  a  straight  tube  of 
thin  silver-plated  brass.  A  central  stilette,  which  is  removable, 
carries  the  obturator  and  the  handle.  Two  centimetres  of  the 
handle  end  of  the  tube  are  belled  to  become  twice  the  diameter 
of  the  rest  of  the  tube.  The  tubes  for  the  uterus  and  for  the 
bladder  in  women  are  g  vivi.  and  13  ;//;//.  in  diameter,  respectively. 


Fig.  42. — Endoscopic  tube  for  examining  male  bladder. 


J.  HEYNBERS—CO. 


Fig.  43. — Forceps  for  introducing  catheter  or  removing  small  objects  from  the  bladder. 


J.  REYNDERS—CO. 

Fig.  44. — Flexible  rectal  elevator  for  manipulating  walls  of  bladder. 


The  length,  exclusive  of  plug  and  stilette,  is  13  ctiii.  The  tubes 
for  inspection  of  the  male  bladder  are  of  the  same  respective 
diameters,  but  of  the  length  of  24  ct^n.  exclusive  of  handle  and 
obturator.  It  is  usually  necessary  in  examining  the  male  bladder 
with  the  large  tube  to  first  nick  the  meatus  and  pass  a  sound. 

The  tubes  for  the  examination  of  the  uterus  and  the  bladder  in 
the  female  are  furnished  with  a  simple  plug  obturator,  but  for  the 
examination  of  the  male  bladder  a  dilatable  obturator  is  used  in 
order  to  fit  the  shoulder  of  the  entering  end  of  the  tube,  and  thus 

117 


1 1 S  Notes. 

make  an  even  surface  which  will  not  catch  the  urethra  at  curves. 
The  obturator  is  dilated  by  turning  the  screw  handle,  which  pushes 
a  wedge  rod,  between  the  wings  of  which  the  obturator  is  com- 
posed. The  obturator  is  composed  of  two  sets  of  wings,  sur- 
mounted by  a  removable  knob.  When  the  instrument  is  to  be 
cleansed,  the  knob  is  unscrewed,  the  two  sets  of  wings  are  pulled 
apart,  and  each  separate  wing  is  unjointed  from  its  fixation  pin. 
Straight  tubes  which  have  been  invented  for  examination  of  the 
male  bladder  have  been  too  small,  and  the  obturators  have  been 
dif^cult  to  cleanse.  The  tube  which  I  use  does  away  with  these 
objections.  Formerly  I  examined  the  bladder  Avith  the  patient  in 
the  supine  position,  but  in  a  position  which  allowed  the  bladder 
to  contract,  and  this  gave  a  field  of  view  equal  to  the  diameter  of 
the  tube  only,  so  that  it  was  often  a  laborious  process  to  find  the 
openings  of  the  ureters  or  to  examine  any  definite  part  of  the 
bladder.  It  was  necessary  to  insert  an  elevator  into  the  rectum 
to  lift  the  trigone  of  the  male  bladder  into  view,  and  the  elevator 
must  still  be  used  for  that  purpose  where  the  finger  in  the  rectum 
will  not  answer  the  purpose. 

Kelly,  of  Baltimore,  gave  us  the  greatest  step  in  progress  of  the 
examination  of  the  bladder  through  straight  tubes,  in  a  paper 
published  in  the  American  Journal  of  Obstetrics  in  1894.  Since 
the  publication  of  that  paper  I  have  adopted  his  plan  of  elevating 
the  hips  of  the  patient  until  the  intestines  cease  to  make  pressure 
against  the  bladder,  and  when  the  tube  is  then  inserted,  the  blad- 
der becomes  more  or  less  dilated  with  air,  and  gives  us  an  excel- 
lent view  of  its  walls.  It  is  now,  by  Kelly's  technique,  an  easy 
matter  to  find  the  openings  of  the  ureters  in  women,  but  in  men, 
unless  the  bladder  at  the  opening  of  the  ureter  is  infiamed,  we 
cannot  find  it  until  a  little  gush  of  urine  marks  the  spot.  As  the 
ureter  empties  itself  by  a  quick  contraction  at  short  intervals, 
however,  the  accumulated  drops  of  urine  which  are  forced  out 
can  be  easily  seen.  Another  reason  why  it  is  more  difificult  to  find 
the  ureters  in  men  than  in  women  is  because  the  tube  cannot  be 
moved  through  as  great  a  range  of  motion,  being  limited  by  the 
triangular  ligament  and  the  prostate  gland. 

A  suction  apparatus,  consisting  of  a  syringe  fitted  with  a  small 
rubber  tube,  somewhat  longer  than  the  ordinary  catheter,  serves 
to  empty  the  bladder  of  urine  which  collects  while  an  examina- 
tion is  being  made.  A  very  long  and  slender  pair  of  slide  forceps 
is  useful  for  carrvingr  a  catheter  or  a  whalebone  bougie  into  the 


Endoscopic    Tubes.  i  1 9 

ureter,  or  for  removing  any  small  object,  or  specimens  snipped 
from  the  wall  of  the  bladder. 

In  proceeding  to  examine  the  interior  of  the  uterus,  the  cervi- 
cal canal  is  first  dilated  with  any  proper  instrument.  The  uterus 
is  then  brought  down  and  steadied  with  volsella  forceps  in  cases 
in  which  that  can  be  harmlessly  done,  and  the  tube  is  entered  to 
the  fundus.  The  obturator  is  removed,  and  with  a  head-mirror 
light  is  thrown  through  the  endoscope.  By  turning  the  endo- 
scope properly,  the  openings  of  the  oviducts  can  be  readily  in- 
spected, and  then  on  slowly  withdrawing  the  endoscope,  the 
whole  of  the  interior  of  the  uterus  is  examined.  In  examining 
theinteriorof  the  bladder  in  men  with  light  reflected  from  ahead- 
mirror,  it  is  necessary  to  have  a  stronger  light  than  that  required 
for  the  female  bladder  or  uterus  on  account  of  the  length  of  the 
tube.  Actual  sunlight  is  by  all  means  the  best,  and  when  it  is 
possible  to  do  so,  I  ask  male  patients  to  wait  for  a  clear,  sunny 
day  for  their  examination.  The  endoscopes  are  practical  for  all 
common  diagnostic  purposes  for  which  they  are  intended,  although 
for  examination  of  the  male  bladder  in  certain  cases  the  Nitze 
cystoscope  in  the  hands  of  a  few  experts  is  superior. 


THE  ACTION  OF  TRYPSIN,  PANCREATIC  EXTRACT,  AND 
PEPSIN,  UPON  SLOUGHS  AND  COAGULA. 

Masses  of  putrescible  material  which  must  be  removed  by  the  sur- 
geon sometimes  require  an  extensive  operative  procedure  unless  such, 
masses  can  be  liquefied  and  washed  away.  A  large  psoas  abscess  may 
have  upon  the  walls  of  its  cavity  a  half  pound  of  tenacious,  partially 
organized  lymph  coagula  which  cannot  be  removed  easily  with  the 
curette  and  spoon,  but  which  will  putrefy  and  cause  dangerous  septi- 
cemia if  allowed  to  remain  after  the  abscess  has  been  opened.  In 
some  cases  of  empyema,  or  of  traumatic  pleurisy,  large  masses  of 
lymph  form  bands  and  diaphragms  within  the  chest  cavity,  and  loose 
masses  of  coagula,  which  are  too  large  to  escape  through  the  surgeon's 
incision,  remain  behind  to  decompose.  The  bladder  is  sometimes  filled 
with  blood  clot.  Sloughs  which  are  undergoing  decomposition,  but 
which  cannot  be  peeled  away  from  a  wound,  may  require  removal  by 
operation  to  prevent  septic  complications.  In  all  of  these  cases  the 
masses  of  putrescible  material  can  be  liquefied  promptly  and  harmlessly 
if  a  digestive  ferment  can  be  properly  applied  to  them. 

The  necessity  for  such  a  resource  first  came  to  me  in  a  case  of 
crushed  liver  resulting  from  a  violent  horse  kick.  A  large  part  of  the 
liver  seemed  to  have  been  destroyed  by  the  blow,  and  an  abscess  cavity 
filled  with  several  quarts  of  blood  and  thin  brownish  pus  had  quickly 
formed,  but  was  walled  in  with  peritoneal  exudate.  A  long  incision 
below  the  right  costal  border  evacuated  the  abscess  contents,  and  dis- 
closed black  and  sloughing  masses  of  crushed  liver,  which  I  tried  to 
excise,  but  wich  the  production  of  such  alarming  hemorrhage  that  it 
was  impossible  to  proceed.  Pultaceous  lymph  coagula  were  attached 
to  the  walls  of  the  cavity  in  places,  and  fibrinous  blood  coagula  formed 
stringy  bridges  across  the  lacerated  structures. 

Into  this  unpromising  wound  we  injected  an  acidulated  solution 
of  pepsin,  which  was  washed  out  with  hydrogen  dioxide  about  two 
hours  later.  The  process  was  then  repeated  at  intervals  during  a  period 
of  forty-eight  hours,  by  the  family  physician,  who  reported  at  the  end 
of  that  time  that  the  last  of  the  sloughs  and  coagula  had  become  lique- 
fied and  had  passed  out  of  the  wound  in  the  form  of  a  voluminous, 
treacly  fluid,  brownish  at  first  and  finally  straw-colored.  The  cleansed 
cavity  rapidly  contracted,  and  the  patient  made  an  excellent  recovery. 

1 20 


Digestive  Ferments  in  Surgery.  i  2 1 

After  experience  with  this  case  experiments  were  tried  with  different 
digestive  ferments.  On  theoretical  grounds  I  had  supposed  that  trypsin 
would  be  the  best  liquefier,  that  pancreatic  extract  would  stand  next  in 
value,  and  that  pepsin  would  be  used  only  when  it  was  inconvenient  to 
obtain  other  ferments  ;  but  in  the  practical  tests  pepsin  proved  to  be 
the  most  efficient.  It  is  not  necessary  to  actually  digest  the  substances 
which  are  to  be  removed,  as  liquefaction  of  the  masses  is  all  that  the 
surgeon  requires  of  the  ferment.  For  test  purposes,  tough,  partially- 
dried  coagula  from  beef's  blood  were  employed,  and  the  trypsin,  pan- 
creatic extract,  and  pepsin  were  obtained  fresh  from  the  works  of  Fair- 
child  Brothers  &  Foster.  As  a  result  of  several  experiments,  it  was 
determined  that  four  grammes  of  pepsin  dissolved  in  three  hundred 
cubic  centimetres  of  water  acidulated  with  one  per  cent,  of  hydrochloric 
acid  and  applied  to  one  hundred  grammes  of  the  coagula  at  a  tempera- 
ture of  about  100°  F.,  would  liquefy  the  coagula  in  thirty-six  minutes. 
Pancreatic  extract  in  alkaline  solution,  with  proportions  and  conditions 
as  in  the  pepsin  experiment,  required  one  hundred  and  forty-six  minutes 
for  liquefying  the  coagula,  and  some  small  knots  of  fibrin  remained 
even  then.  Trypsin  in  alkaline  solution,  used  with  proportions  and 
conditions  as  in  the  pepsin  experiment,  required  one  hundred  and 
thirty  minutes  for  liquefying  the  one  hundred  grammes  of  coagula. 
Two  grammes  of  tough  lining  membrane  from  the  cavity  of  a  coxitis 
abscess  were  liquefied  in  fifty-five  minutes  with  the  pepsin  solution. 

Since  these  tests  were  made,  I  have  had  occasion  to  employ  pepsin 
solution  for  various  surgical  conditions,  and  have  determined  that  there 
are  some  precautions  to  be  observed.  The  pepsin  solution  used  in  the 
vicinity  of  new  scar  tissue  will  dissolve  it,  and  cause .  the  wound  to 
gape.  It  will  also  liquefy  catgut  sutures  and  ligatures.  Although 
pepsin  attacks  dead  tissue  rapidly,  it  does  not  seem  to  exert  a  harmful 
influence  on  tissues  in  which  blood  is  circulating.  Thus,  the  stomach 
walls  do  not  digest  while  the  tissues  are  normal  and  living  ;  but  if  an  ulcer 
of  the  stomach  causes  a  sufficient  degree  of  exudation  anemia  at  any 
one  point,  a  perforation  of  the  stomach  may  be  caused  by  the  digestion 
of  the  anemic  spot.  A  very  good  illustration  of  the  action  of  digestion 
of  tissues  is  furnished  in  trout  which  have  been  caught  on  a  warm  day, 
particularly  when  the  stomach  has  been  torn  by  a  swallowed  hook. 
In  such  a  trout  the  viscera  are  found  to  be  partially  liquefied  when  the 
trout  are  dressed  a  few  hours  later. 

A  thick  solution  of  pepsin  is  not  so  effective  as  a  thin,  watery  solu- 
tion, for  pepsin  normally  requires  a  good  deal  of  water  for  its  best 
action.  The  proportions  of  the  solutions  for  surgical  purposes  are  as 
follows  :  Distilled  water,  four  fluid  ounces  ;  hydrochloric  acid,  U.S.P., 
sixteen  minims  ;    best  scale  pepsin,  half  a  drachm. 


I  2  2  Notes. 

The  glycerine  extract  of  pepsin,  and  papoid,  have  been  recently  rec- 
ommended as  particularly  good  preparations  for  the  surgeon's  use  ;  the 
papoid  because  it  can  be  sterilized  without  destroying  its  efficiency,  and 
because  it  is  active  in  both  acid  and  alkaline  media,  but  I  have  had  no 
opportunity  to  make  accurate  tests  with  anything  excepting  the  diges- 
tive ferments  as  described. 

After  liquefying  sloughs  and  coagula,  I  usually  cleanse  the  wound 
with  hydrogen  dioxide,  and  then  stimulate  the  tissues  to  the  formation 
of  granulations  with  balsam  of  Peru  ;  but  after  the  removal  of  clots 
from  the  bladder,  special  cleansing  is  unnecessary. 


THE  REMOVAL  OF  NECROTIC  AND  CARIOUS  BONE  WITH 
HYDROCHLORIC  ACID  AND  PEPSIN. 

Sometimes  it  is  desirable  to  remove  dead  bone  without  subjecting 
the  patient  to  an  extensive  operation.  Attempts  have  been  made  with 
some  success  at  clearing  out  this  bone  by  a  process  of  decalcification, 
b)ut  there  was  one  chief  reason  why  failures  have  resulted.  It  was  dis- 
covered that  superficial  layers  of  dead  bone  were  decalcified  easily 
enough,  but  the  acids  did  not  reach  deeply  into  the  mass,  especially  if 
portions  were  infiltrated  with  caseous  or  fatty  debris.  After  much  ex- 
perimentation, I  have  adopted  a  method  of  work  which  is  satisfactory 
in  selected  cases. 

An  opening  is  made  through  the  soft  parts,  if  necessary,  by  means 
■of  a  direct  incision  to  the  seat  of  dead  bone,  and  if  many  sinuses  are 
present  they  are  led,  if  possible,  into  one  large  sinus.  The  large  direct 
sinus  is  kept  open  Avith  strips  of  gauze  soaked  in  balsam  of  Peru,  and 
the  wound  is  allowed  to  remain  quiet  until  granulation  tissue  is  well 
formed.  The  next  step  consists  in  injecting  into  the  sinus  a  three  per 
cent,  solution  of  hydrochloric  acid  in  distilled  water.  If  the  patient  is 
confined  to  bed,  the  injections  can  be  made  at  intervals  of  two  hours 
during  the  day  ;  but  if  it  is  best  to  keep  the  patient  out  of  bed,  the  acid 
solution  is  thrown  into  the  sinus  less  frequently,  and  the  patient  in  either 
case  must  assume  a  position  favorable  for  the  retention  of  the  solution. 
Decalcification  of  exposed  layers  of  dead  bone  takes  place  in  a  few 
liours,  and  then  comes  the  necessity  for  another  and  very  important 
step  in  the  progress.  At  intervals  of  about  two  days  an  acidulated 
pepsin  solution  is  thrown  into  the  sinus  (distilled  water,  four  ounces  ; 
Tiydrochloric  acid,  U.S. P.,  sixteen  minims  ;  scale  pepsin,  half  a  drachm). 
This  solution  will  liquefy  decalcified  bone  and  caseous  and  fatty  debris 
in  less  than  two  hours,  leaving  clean  dead  bone  exposed  for  a  repetition 
of  the  treatment.  The  treatment  is  continued  until  the  sinus  closes  at 
the  bottom,  showing  that  the  dead  bone  is  all  out ;  but  in  progressing 
cases  of  tuberculosis,  it  is  advantageous  to  throw  into  the  sinus  at 
intervals  of  a  week,  a  ten  per  cent,  mixture  of  iodoform  in  glycerine, 
allowing  this  mixture  to  remain  in  place  for  twenty-four  hours.  In 
tortuous  channels  which  will  not  receive  the  thick  glycerine  mixture,  a 
seven  per  cent,  ethereal  solution  of  iodoform  may  be  used  in  its  place. 
In  tuberculous  cases,  apparatus  for  immobilizing  diseased  parts,  and 


124 


Notes. 


tonic  constitutional  treatment  are  necessary  in  conjunction  with  the 
treatment  for  the  removal  of  dead  bone.  If  a  cavity  in  which  we  are 
at  work  is  suppurating  freely,  it  should  be  cleansed  with  boiled  water 
before  medicated  injections  are  employed. 

It  is  a  popular  impression  that  living  bone  is  not  attacked  by  very- 
dilute  solutions  of  mineral  acids.  In  order  to  test  this  point  I  made 
the  following  experiments  :  A  portion  of  the  keratinoid  layer  was  re- 
moved from  the  carapace  of  a  live  turtle  {Nanemys guttatus),  and  the 
animal  was  then  placed,  tail  downward,  in  a  glass  of  five  per  cent,  hy- 


FiG.  45. — Dark  portion,  decalcified  bone,  which  is  stained  with  carmine 
up  to  the  light  portion,  living  bone. 

drochloric  acid  solution.  In  the  same  glass  I  placed  a  segment  snipped 
from  the  plastron  of  the  turtle,  and  also  a  thin  transverse  segment  from 
an  old,  dry  humerus  from  a  man.  The  piece  of  humerus  was  decalcified 
in  six  hours  ;  the  piece  of  plastron  was  distinctly  softened  in  twenty 
hours,  and  the  submerged  portion  of  the  exposed  living  carapace  was 
decalcified  in  thirty  hours.  I  was  then  curious  to  note  what  effect  the 
acid  had  produced  on  the  carapace,  and  sections  for  microscopical 
examinations  were  made,  which  included  both  decalcified  and  normal 
bone.  These  sections  were  stained  with  carmine.  Investigation 
showed  that  all  of  the  blood-vessels  were  destroyed  wherever  the  bone 


Removal  of  Necrotic  Bone. 


125 


was  softened,  and  the   action   of  the   acid  had  extended  farther  along 
the  line    of  the  larger  blood-vessels  than  elsewhere. 

In  the  accompanying  photo-micrographs  taken  from  these  slides,  the 
dark  portions  show  decalcified  bone  stained  with  carmine,  and  in  the 
lighter  portions  normal  bone  is  distinguished.  In  Figure  46  can  be  seen 
the  line  of  extension  of  decalcification  along  the  course  of  three  blood- 
vessels. The  difference  in  time  required  for  decalcification  of  the  dead 
bone  (six  hours)  and  of  the  living  bone  (thirty  hours)  is  significant,  a 
five  percent,  solution  having  been  used.     If  we  use  a  three  per  cent. 


Fig.  46. — Dark  lines  showing  decalcification  along  lines  of  blood-vessels, 
carmine  stain. 


solution  of  hydrochloric  acid  in  practice,  a  wall  of  granulation  sur- 
face is  thrown  out  upon  the  surface  of  living  bone  so  that  dead  bone 
only  undergoes  destruction,  according  to  my  observation  in  several 
cases  in  which  the  results  of  treatment  could  be  watched. 

This  plan  of  treatment  is  not  to  be  depended  upon  for  progressing 
cases  of  tuberculosis  or  osteo-myelitis  of  the  bones,  but  sometimes  it 
works  beautifully  in  such  cases.  Its  principal  field  for  usefulness  is  in 
cases  which  are  not  progressing  and  in  which  dead  bone  has  been  left 
behind  as  the  result  of  any  destructive  process. 


IS  EVOLUTION  TRYING  TO  DO  AWAY  WITH   THE 
CLITORIS? 


During  a  period  of  twelve  months  I  collected  statistics  from  some 
three  hundred  cases,  which  showed  that  about  eighty  per  cent,  of  Aryan- 
American  women  possess  preputial  adhesions,  which  bind  together 
the  glans  of  the  clitoris  and  its  prepuce.  The  condition  evidently  repre- 
sents a  degenerative  process  that  goes  with  higher  civilization.  It  dates 
back  to  the  embryonic  life  of  the  individual,  and  consists  anatomically  in 


Fig.  47. — Section  of  apex  of  normal  glans  clitoridis,  and  prepuce. 

a  failure  of  the  genital  eminence  to  develop  its  epithelial  surfaces  per- 
fectly enough  for  complete  cleavage  between  the  opposed  surfaces  of 
the  prepuce  and  glans  of  the  clitoris.  This  degeneration  sign  is  as  well 
marked  as  those  furnished  by  poorly  developed  mammary  glands, 
early  falling  hair,  and  teeth  which  are  prone  to  decay. 

Preputial  adhesions  in  women  are  similar  in  character  to  those  which 
occur  less  frequently  in  men,  and  the  resulting  disturbances  are  alike 

126 


Evolution  and  tJie  Clitoris. 


T  27 


in  both  sexes,  but  greater  in  degree  in  women  because  of  the  more  im- 
pressionable nervous  system  of  that  sex.  Adhesions  may  bind  down 
the  prepuce  so  closely  that  no  part  of  the  glans  clitoridis  is  in  sight. 
They  may  involve  half  of  the  glans,  or  they  may  form  only  a  small 
adherence  which  is  of  no  importance  excepting  as  an  anatomical  curi- 
osity. This  curiosity  is  serious,  is  portent,  however,  for  Nature  in 
failing  persistently  to  develop  the  part  indicates  that  it  is  intended  that 
the  clitoris  is  to  disappear  as  civilization  advances.  The  adherent  pre- 
puce is  important  not  only  as  a  degeneration  sign,  but  in  children  and 
in  young  women  it  sometimes  produces   such  an  impression  upon  the 


Fig.  48. — Section  of  adherent  glans  clitoridis  and  prepuce. 
Dark  line  of  adhesion. 


nerve  centres  that  the  whole  sexual  apparatus  is  influenced  toward 
degeneration — a  result,  rather  than  a  coincidence,  in  at  least  some 
of  the  observed  cases  which  recovered  from  the  beginning  degeneration 
of  the  uterus  and  adnexa  after  circumcision  had  been  performed.  The 
glans  clitoridis  confined  among  adhesions,  fails  to  develop,  and  remains 
small  and  compressed.  The  glands  of  the  mucous  membrane  of  the 
prepuce  also  fail  to  develop  at  the  points  of  adhesion.  It  is  a  remark- 
able fact,  however,  that  when  adhesions  have  been  separated,  and  the 
prepuce  prevented  from  re-adhering  to  the  glans  of  the  clitoris,  the 
glans  will  in  a  few  weeks  develop  to  what  is  apparently  a  normal  size. 
The  glands  of  the  mucous  membrane  at  the  same  time  become  perfect, 


128  Notes. 

as  determined  from  typical  specimens  removed  for  examination,  fur- 
nishing abundant  normal  secretion  ;  and  these  restorative  changes  take 
place  even  after  years  of  repression.  I  know  of  nothing  analogous 
among  the  higher  vertebrata. 

There  were  ten  negresses  among  the  patients  examined,  and  prepu- 
tial adhesions  were  found  in  three  who  very  likely  possessed  an  admix- 
ture of  Caucasian  blood.  In  the  others,  the  glans  and  prepuce  were 
perfectly  developed.  A  number  of  highly  domesticated  animals  were 
examined  for  me  by  Professor  James  Law,  who  stated  that  in  them  the 
glans  cliioridis  was  free,  and  the  prepuce  not  adherent,  excepting  as  the 


Fig.  49. — Space  for  encapsulated  smegma  in  adhesion  line. 

occasional  result  of  parturition  injury.  A  large  number  of  Semitic 
women  among  the  patients  showed  very  little  tendency  to  preputial 
adhesions,  and  the  glans  and  prepuce  were  in  them  usually  as  well 
developed  as  were  tlieir  mammary  glands.  This  fact  is  extremely 
interesting,  as  compared  with  the  great  proportion  of  clitoris  and  mam- 
mary degeneration  signs  in  Aryan  American  women,  and  would  indi- 
cate that  the  Semitic  people  are  to  outlast  us. 

Some  of  the  phenomena  of  physical  degeneration  of  civilized  races 
are  of  interest  only  as  evidences  of  retrogression,  but  preputial  adhe- 
sions in  children  and  young  women  are  malevolent  in  influence  when 
they  involve  much  of  the  glans  of  the  clitoris.  The  disturbance  caused 
by  preputial  adhesions  depends  primarily  upon  irritation  of  the  terminal 


Evolution  and  iJie  Clito^Hs.  129 

branches  of  the  pudic  nerve  in  the  attempt  of  the  erectile  ^lans  clit07-idis 
to  adjust  itself  to  the  less  elastic  prepuce  ;  and  it  depends  secondarily 
upon  the  irritation  caused  by  retained  secretions.  The  retained  smegma 
is  usually  found  in  the  form  of  small,  white  inspissated  particles,  but 
sometimes  a  small  area  of  developed  glands  secrete  enough  to  cause 
tension  among  the  adhesions,  and  when  retained  smegma  happens  to 
become  transformed  into  an  acrid,  thin  fiuid,  it  finds  a  point  for  grad- 
ual escape,  and  causes  pruritus  or  even  excoriations  about  the  vulva. 
Some  of  the  cases  of  suppurating  vulvitis  in  children  begin  at  such 
small  excoriations  about  the  prepuce,  in  which  local  inflammation  is 
caused  by  retained  smegma,  but  these  are  not  so  commoti  or  so  impor- 
tant as  the  ones  of  simple  irritation  from  incarceration  of.  the  erectile 
glans  clitoridis.  The  irritation  of  preputial  adhesions  early  attracts  the 
attention  of  the  child  to  that  part,  which  is  frequently  rubbed  to  give 
relief,  until  the  habit  often  becomes  a  fixed  one — innocently  on  her 
part — as  the  girl  grows  older,  and  neurasthenia  results.  Any  one  who 
has  previously  had  no  occasion  to  make  inquiries  of  girls  who  suffer 
from  adherent  prepuces  will  be  surprised  at  the  answers  to  his  inquiries 
relative  to  the  frequency  with  which  they  feel  impelled  to  rub  the  irri- 
table region.  The  subject  needs  the  immediate  and  direct  attention  on 
the  part  of  every  woman  physician  in  the  country  to-day. 

After  collecting  enough  cases  for  statistical  purposes,  I  dropped  the 
subject,  as  it  is  naturally  repelling  to  one  of  the  opposite  sex,  but  the 
proper  persons  must  at  once  take  up  this  work  of  looking  after  adherent 
prepuces  in  young  girls.  In  making  inquiries  of  the  patient  it  is  well 
to  state  that  signs  of  local  irritation  are  discovered,  and  then  the 
patient,  knowing  that  we  have  a  clue,  will  freely  state  what  she  other- 
wise might  deny. 

As  a  result  of  continued  adhesion  irritation,  or  of  neurasthenia  from 
the  effect  of  rubbing,  a  second  series  of  disturbances  appears — the 
reflex  neuroses,  and  in  this  group  of  symptoms  we  have  the  most  com- 
plicated and  the  most  harmful  of  the  influences  emerging  from  the 
peripheral  irritation  at  the  clitoris.  Chronic  peripheral  over-stimula- 
tion of  the  centripetal  nerves  connected  with  the  centres  of  the  spinal 
cord  and  brain  lead  in  ordinary  concatenation  (i)  to  the  common 
acute  reflex  demonstrations;  (2)  to  slow  degenerative  changes  in  organs 
the  functions  of  which  have  been  disturbed  ;  and  (3)  to  complications 
dependent  upon  such  degenerations.  For  instance,  if  preputial  irrita- 
tion neurasthenia  leads  to  relaxation  of  the  uterine  ligaments,  and  the 
resulting  malposition  of  the  uterus  leads  to  degeneration  of  the  ovaries, 
the  patient  may  suffer  more  from  the  ovarian  complication  than  from 
the  original  cause  for  that  complication,  but  the  removal  of  the  ovaries 
will  not  make  her  well.     The  fast  growing  girl  with  preputial  adhesions 


130  Notes. 

may  become  languid  enough  to  sag  into  scoliosis,  and  no  amount  of 
orthopedic  treatment  will  stop  the  scoliosis,  which  is  but  a  symptom 
in  her  case.  The  young  asthmatic,  the  girl  whose  uterus  is  ante- 
flexed,  the  child  who  is  listless  and  fretful  and  fanciful  as  to  her 
food,  the  patient  with  enuresis  or  with  dysuria,  and  with  menstrual 
irregularities,  the  hysteric,  the  patient  with  epileptoid  convulsions,  the 
patient  with  nervous  dyspepsia  or  spasmodic  stricture  of  the  cesophagus^ 
or  non-inflammatory  paralyses  of  the  legs  — all  of  these  must  be  ex- 
amined by  the  diagnostician  for  preputial  adhesions.  1  do  not  wish  to 
be  understood  as  underrating  ±he  importance  of  any  of  the  other  well 
known  causes  for  the  same  symptoms — errors  of  refraction  perhaps 
standing  first  in  causal  relation  for  many  of  them, — but  would  simply 
state  that  preputial  adhesions  are  the  prime  factor  in  a  sufficient  pro- 
portion of  the  cases  to  at  least  make  it  necessary  for  us  to  eliininate 
that  factor  whenever  it  is  found. 

Before  neurotic  habits  have  become  established,  the  symptoms  which 
are  dependent  upon  preputial  adhesions  will  often  disappear  as  quickly 
as  does  sciatica  that  is  dependent  upon  Dupuytren's  contraction  of  the 
palmar  fascia,  or  the  cough  which  is  dependent  upon  a  bean  in  the  ear, 
when  the  cause  is  removed.  With  older  patients  in  whom  neurotic 
habits  have  become  established,  the  results  are  not  so  immediate  or  sO' 
well  marked  as  in  children.  In  few  patients  beyond  the  age  of  twenty- 
five  years  is  very  much  gained  by  the  separation  of  preputial  adhesions,, 
although  chronic  local  irritation  may  be  stopped  and  some  unresponsive 
wives  find  that  the  clitoris  was  at  fault.  The  proper  time  for  the 
separation  of  preputial  adhesions  is  when  the  babe  is  first  born,  and 
as  a  matter  of  routine  practice.  Baker  Brown,  I  believe,  was  very 
near  to  the  subject  of  preputial  adhesions  when  he  published  his  work  on 
The  Curability  of  Various  Forms  of  Insanity,  Epilepsy,  Catalepsy,  and- 
Hysteria,  but  his  method  consisted,  not  in  the  separation  of  adhesions,, 
but  in  the  bodily  removal  of  the  offending  clitoris,  and  he  ignored  as 
much  physiology  as  is  ignored  by  many  other  observers  who  find 
revelations  along  a  new  line  of  investigation,  and  who  try  to  leaven  too 
big  a  lump  with  their  findings. 

Some  of  the  results  of  separating  preputial  adhesions  are  so  striking- 
that  one  finds  it  hard  to  avoid  giving  too  much  importance  to  the  sub- 
ject as  a  whole.  One  of  my  patients  who  suffered  from  epileptoid 
seizures,  with  several  attacks  weekly,  simulating  ^r««^  vial,  is  reported 
by  the  family  physician  as  having  had  no  attacks  for  a  year  since  cir- 
cumcision was  performed  on  her.  In  another  case,  with  a  separation 
of  adhesions  without  circumcision,  there  was  a  tendency  to  re-adhe- 
sion. The  patient  was  free  from  epileptoid  convulsions  when  the  pre- 
puce was  free,  but  suffered  from  such  attacks  when  the  prepuce  became- 


Evolution  and  the  Clitoris.  1 3 1 

re-adherent.  Medication  was  discontinued  at  the  time  in  both  cases, 
and  not  resorted  to  while  tlicy  were  under  observation.  Nocturnal 
enuresis  was  promptly  stopped  in  several  of  my  patients  by  separation  of 
preputial  adhesions  from  \.\\q  glans  cliioridis.  Very  many  neurasthenic 
girls  made  prompt  and  striking  improvement  as  the  result  of  the  same 
treatment.  In  a  word,  I  may  say  that  separation  of  preputial  adhesions 
in  girls  accomplishes  just  what  it  does  in  boys,  plus  relief  from  such 
uterine  and  ovarian  complications  as  are  dependent  upon  that  cause, 
and  they  are  not  few.  Sayre,  Ricketts,  Remondino,  and  others  have 
called  attention  to  the  clinical  importance  of  preputial  adhesions  in 
girls,  but  the  subject  has  not  as  yet  found  its  stable  position  in  medical 
history. 

After  separation  of  preputial  adhesions,  there  is  a  marked  tendency 
for  them  to  recur,  and  excepting  in  infants,  I  now  advocate  the  removal 
of  the  prepuce  instead  of  simply  separating  it  from  the  glans.  The 
work  can  be  done  under  cocaine,  if  cocaine  is  injected  hypodermati- 
cally  into  the  glans  and  into  the  prepuce,  but  on  account  of  the  sensi- 
tiveness of  this  region  to  the  entrance  of  a  needle,  it  is  much  better  to 
give  these  patients  ether,  as  that  allows  of  much  better  work  being 
done.  The  prepuce  is  first  stripped  away  from  the  glans  with  the 
handle  of  the  scalpel  until  the  corona  is  free.  The  prepuce  is  then 
split  through  the  middle  and  the  folds  on  either  side  of  the  glans  are 
picked  up  with  a  pair  of  thumb  forceps  and  cut  off  with  scissors. 
Enough  must  be  cut  off  to  prevent  re-adhesion  between  the  glans  and 
any  remaining  prepuce.  It  is  not  worth  while  to  stop  the  oozing  of 
blood  which  follows  the  operation,  as  that  will  soon  cease  spontaneous- 
ly. Aristol  is  dusted  on  the  wound  daily  until  it  has  healed.  It  is  not 
always  an  easy  matter  to  strip  a.  glans  clitoridis  from  preputial  adhesions, 
and  incomplete  work  by  one  who  has  not  a  clear  idea  of  the  appearance 
of  the  normal  glans  will  result  in  disappointment.  This  work  should 
be  done  by  women  physicians  whenever  it  is  possible  to  obtain  their 
services. 


THE  MECHANISM  AND  ANATOMY  OF  SUBLUXATION 
OF  THE  HEAD  OF  THE  RADIUS. 

In  order  to  verify  a  theory  which  had  already  been  accepted  by 
some  as  tenable  in  reference  to  the  anatomy  of  that  common  injury  of 
childhood  known  as  subluxation  of  the  head  of  the  radius,  I  made  the 
following  experiments  : 

Two  arms  from  a  child  four  months  of  age,  and  two  arms  from  a 
child  fourteen  months  of  age,  both  children  dead  a  few  hours,  were 
placed  in  a  weak  acidulated  bichloride  of  mercury  solution,  and  the 
experiments  were  made  during  the  next  twenty-four  hours. 


Fig.  50. — Orbicular  ligament  in  normal  position. 


Fig.  51. — Orbicular  ligament  slipped  between  head  of  radius  and  capitellum. 

Experiment  No.  i.  Left  arm  of  four-months-old  child— all  muscles 
dissected  apart  from  each  other,  but  not  removed,  and  ligaments  of 
elbow  freely  exposed.  Traction  with  the  hands  was  made  upon  the 
radius  and  humerus  simultaneously,  and  with  varying  degrees  of  force. 

Observation.  Separation  of  head  of  radius  from  capitellum,  and  of 
head  of  ulna  from  trochlea  ;  depression  of  ligaments  into  joint  space 
as  a  result  of  atmospheric   pressure  ;    spontaneous  restoration  of  ail 

132 


Stibluxaiiou  of  the  Radius.  133 

structures  to   their  normal   position  immediately    upon  being  relieved 
from  traction  force.      Subluxation  not  produced. 

Experiment  No.  2.  The  same  arm  ;  all  muscles  removed.  Repeated 
traction  was  made  upon  the  radius  and  ulna  with  the  bones  of  the  arm 
in  various  positions  of  flexion  and  rotation. 

Observation.     The  same  as  in  experiment  No.  i. 

Experiment  No.  3.  Right  arm  of  fourteen-months  old  child;  muscles 
of  arm  removed  with  exception  of  biceps  ;  simultaneous  traction  upon 
radius  and  humerus. 

Observation.  Separation  of  articular  surfaces  of  radius  and  ulna 
from  capitellum  and  trochlea  ;  depression  of  ligaments  into  joint  space; 
sudden  slipping  of  loop  of  orbicular  ligament  over  head  of  radius,  and 
into  joint  space  between  head  of  radius  and  capitellum  ;  orbicular  loop 
remains  interposed  between  head  of  radius  and  capitellum  when  trac- 
tion force  is  discontinued  ;  articular  surfaces  of  head  of  ulna  and 
trochlea  remain  slightly  separated  because  of  the  ligamentous  wedge 
made  by  the  orbicular  loop  between  radial  head  and  capitellnm. 
Subluxation  produced.  Slight  apparent  deformity.  A  clicking  sound 
is  produced  by  rocking  the  articular  surfaces  of  the  ulna  and  humerus 
together.  The  joint  movements  are  almost  complete,  but  flexion  is 
slightly  limited  through  the  last  few  degrees  of  range.  Reduction  of 
the  orbicular  ligament  is  difficult,  but  is  finally  accomplished  by  rotat- 
ing the  radius  into  pronation  and  pressing  the  joint  surfaces  together  at 
the  same  time.  The  reduction  is  sudden,  and  takes  place  v/ith  an  aud- 
ible snap.  There  is  then  restoration  of  all  structures  to  their  normal 
positions,  but  the  orbicular  ligament  appears  to  be  more  loosely  attach- 
ed to  the  surroundings  than  before  on  account  of  the  stretching  of  its 
connective-tissue  attachments. 

Experiment  No.  4.  Same  arm  ;  radius  and  ulna  held  in  my  left  hand, 
and  humerus  in  my  right  hand.  The  specimen  was  held  with  its 
elbow  in  an  extended  or  partially  flexed  position,  and  pressure  was 
made  with  my  thumb  on  the  outer  surface  of  the  head  of  the  radius, 
forcing  it  slightly  away  from  the  capitellum,  and  mesially  toward  the 
ulna. 

Observation.  Subluxation  of  the  head  of  the  radius  is  produced  in 
the  same  anatomical  way  as  when  traction  force  was  applied  in  the 
long  axis  of  the  radius. 

Experifjient  No.  j.  Same  arm  ;  subluxation  reduced  ;  biceps  put 
upon  the  stretch  in  its  normal  axis  of  traction,  and  efforts  then  made 
to  produce  subluxation  by  traction  upon  the  radius  and  humerus  with 
my  hands,  and  by  pressure  upon  the  outer  surface  of  the  head  of  the 
radius  with  my  thumb. 

Observation.     It  is  at  once  apparent  that  subluxation  of  the  head  of 


1 34  Azotes. 

the  radius  cannot  be  produced  by  any  mechanism  while  the  biceps 
muscle  is  at  work. 

Experiment  A\k  6.  Left  arm  of  the  four-months-old  child.  Sub- 
luxation \Yas  produced  after  more  violent  movements  of  traction  and 
of  outer  side  pressure  than  I  had  applied  at  first. 

Experiment  No.  '].  Right  arm  of  four-months-old  child.  All  mus- 
cles were  removed  excepting  the  brachialis  anticus  and  supinator  brevis. 
Simultaneous  traction  upon  the  radius  and  humerus  produced  subluxa- 
tion of  the  head  of  the  radius,  and  a  few  fibres  of  both  of  the  muscles 
were  drawn  down  into  the  joint  space  between  the  radical  head  and  the 
capitellum,  along  Avith  the  orbicular  ligament  and  a  part  of  the  anterior 
ligament.  The  subluxation  was  reduced  most  easily  by  strong  prona- 
tion of  the  radius,  very  slight  flexion  of  the  elbow,  and  upward  pressure 
in  the  long  axis  of  the  radius.  As  reduction  of  the  head  of  the  radius 
is  supposed  to  occur  spontaneously  after  a  few  days  in  many  cases,  it 
seemed  to  me  that  such  reduction  could  take  place  only  as  a  result  of 
synovitis,  with  increase  of  synovial  fluid,  and  the  consequent  forcing  of 
the  orbicular  ligament  out  of  the  joint  space. 

For  testimony  bearing  upon  this  point,  I  made  the  following  trial  : 

Experiment  No.  8.  Right  arm  of  four-months-old  child.  Subluxa- 
tion produced.  About  forty  minims  of  water  were  injected  into  the 
joint  cavity  through  a  fine  hypodermic  needle. 

Observation.  Tension  of  the  capsule,  quick  and  strong  flexion  of  the 
forearm  upon  the  arm,  and  pronation  of  the  forearm,  made  by  pressure 
of  the  injected  water.  Orbicular  ligament  remains  hopelessly  locked 
within  the  joint  space  between  the  head  of  the  radius  and  capitellum. 
Condition  less  favorable  for  spontaneous  reduction  than  when  the  joint 
was  empty  of  water. 

Experiment  N'o.  g.  Left  arm  of  fourteen-months-old  child.  Muscles 
dissected  away  from  each  other,  but  not  removed.  Attempts  were 
made  at  producing  subluxation  by  pressure  with  the  thumbs  upon  the 
outer  surface  of  the  head  of  the  radius,  and  resulted  in  ordinary  luxa- 
tion of  the  head  of  the  radius  anteriorly.  The  head  of  the  radius  tore 
through  the  anterior  ligament  proximally  to  the  orbicular  ligament. 

Conchisions  from  these  nine  experiments. 

(i)  Subluxation  of  the  head  of  the  radius  consists  in  the  separation 
of  the  head  of  the  radius  from  the  capitellum  by  the  interposition  be- 
tween them  of  a  loop  of  the  orbicular  ligament,  which  is  accompanied 
in  some  cases  by  a  small  portion  of  the  anterior  ligament  of  the  elbow) 
and  some  fibres  of  the  brachialis  anticus  and  supinator  brevis  muscles. 
The  articular  surfaces  of  the  head  of  the  ulna  and  of  the  trochlea 
remain  slightly  separated  at  the  time,  because  of  the  wedge  of  orbicu- 


Subluxation  of  the  Radius.  1 3  5 

lar  ligament  between  the  head  of  the  radius  and  the  capitellum.  Pas- 
sive movements  of  the  joints  give  rise  to  clicking  sounds,  caused  by  the 
rocking  together  of  the  separated  ulnar  and  humeral  articular  surfaces. 
There  is  no  appreciable  deformity  on  inspection  or  palpation,  but  the 
range  of  motion  of  the  forearm  upon  the  arm  is  slightly  limited. 

(2)  The  accident  occurs  at  an  instant  when  the  biceps  muscle  is  re- 
laxed, and  as  a  result  of  direct  traction  force  upon  the  radius  while  the 
forearm  is  in  a  position  of  partial  or  complete  supination.  It  also  oc- 
curs under  the  same  anatomical  conditions  when  the  force  is  applied 
directly  to  the  outer  side  of  the  radius,  forcing  the  head  of  the  radius 
anteriorly  and  a  little  proximally  from  the  humerus.  The  former 
mechanism  is  brought  into  play  when  a  child,  led  by  the  hand,  stumbles 
and  falls,  its  hand  remaining  grasped  in  the  hand  of  the  nurse.  The 
latter  mechanism  is  brought  into  play  when  in  a  fall  the  outer  side  of 
the  elbow  strikes  a  stone. 

(3)  The  mechanism  of  spontaneous  reduction  has  not  been  deter- 
mined. It  may  occur  as  a  result  of  swelling  of  the  pinched  ligaments 
and  muscular  fibres,  but  it  is  more  likely  to  be  due  to  absorption  of 
the  portion  of  loop  which  is  subjected  to  the  greatest  degree  of  ten- 
sion and  of  pressure.  A  strand  of  catgut  under  the  same  circum- 
stances would  be  absorbed  in  a  few  days. 

(4)  Reduction  may  be  accomplished  by  the  surgeon,  as  a  result  of 
various  movements  which  tend  to  work  the  head  of  the  radius  back 
under  the  loop  of  orbicular  ligament,  and  the  most  frequently  success- 
ful movement  seems  to  be  pronation  and  pressure  directed  proximallv 
along  the  long  axis  of  the  radius,  the  arm  being  at  the  time  completely 
extended.     An  audible  snap  gives  evidence  of  reduction. 

(5)  In  treating  cases  in  which  reduction  cannot  be  accomplished  by 
the  surgeon,  the  arm  should  be  fixed  in  a  position  of  nearly  complete 
extension,  as  this  gives  the  loop  of  orbicular  ligament  the  best  oppor- 
tunity to  escape  according  to  the  testimony  of  my  small  number  of 
specimens. 

(6)  The  muscular  disability  of  the  arm  during  the  early  days  of  the 
injury  is  apparent  rather  than  real,  as  I  have  demonstrated  in  one 
adult  patient  who  made  intelligent  observations.  Eecause  of  the  pain 
consequent  upon  movements  at  the  elbow  joint  the  patient  could  with 
difficulty  be  persuaded  to  move  the  arm  at  all,  but  movements  once 
begun,  she  could  carry  the  forearm  through  almost  its  complete  range 
of  motion. 

(7)  An  injury  which  has  for  its  principal  feature  a  displaced  orbicu- 
lar ligament,  would  be  correctly  described  as  "  dislocation  of  the 
orbicular  ligament"  rather  than  as  "  subluxation  of  the  head  of  the 
radius." 


POTT'S  FRACTURE,  AND  THE  FRACTURE  OF  THE  FIBULA 
WHICH  FOLLOWS  ADDUCTION  OF  THE  FOOT. 

The  following  experiments  were  made  for  verification  of 
theories  \vhich  are  subject  to  variance  among  authors  as  to  the 
mechanism  which  is  involved.  Pott's  fracture  is  not  so  common 
as  fracture  following  adduction  of  the  foot,  and  yet  the  two  are 
apt  to  be  confused  unless  the  surgeon  on  inquiry  learns  from  the 
patient  whether  the  foot  "  turned  in  or  out."  The  large  propor- 
tion of  fractures  which  are  recorded  in  clinical  history  books  as 
cases  of  Pott's  fracture,  are  really  cases  of  fracture  by  adduction 
of  the  foot. 

Pott's  fracture  occurs  when  the  foot  "  turns  out,"  and  fracture 
by  adduction  of  the  foot,  when  it  "turns  in."  In  making  ex- 
periments at  the  morgue,  cadavers  of  people  of  various  ages  were 
employed,  and  usually  with  adults  not  more  than  two  days  after 
death.  The  soft  parts  about  the  ankles  Avere  dissected  away 
excepting  the  ligaments  and  tendons,  and  in  some  of  these  a 
little  window  was  cut  in  the  anterior  ligament  of  the  ankle  joint. 
A  stout  piece  of  board  was  bound  very  firmly  to  the  sole  of  the 
foot,  leaving  space  to  pass  a  broom-handle  between  the  sole  and 
the  board  for  use  as  a  lever.  Fractures  were  then  made  by  turn- 
ing the  foot  quickly  and  violently  in  one  direction  or  the  other  by 
means  of  the  broom-handle  grasped  in  my  hands,  or  by  standing 
the  cadaver  erect  upon  the  abducted  or  adducted  foot,  and  apply- 
ing force  by  pressing  the  cadaver  downward  until  structures  near 
the  ankle  gave  way. 

The  mechanism  of  Pott's  fracture  was  observed  to  be  as  follows 
in  a  series  of  cases  :  When  the  foot  was  turned  outward  (abducted) 
with  a  suf^cient  degree  of  violence,  the  astragalus  rotated  from 
without  inward  on  its  antero-posterior  axis,  and  at  that  instant 
the  tibia  assumed  the  position  of  an  opposing  lever,  the  short  arm 
of  which  was  the  internal  malleolus,  the  long  arm  the  shaft  of  the 
tibia,  and  the  fulcrum  was  composed  of  the  astragalus  and  os  cal- 
cis,  which  retained  their  relative  positions  with  each  other.  The 
principal  object  upon  which  this  lever  acted  was  the  deltoid  liga- 

136 


Fractures  of  the  Fibula.  i  3  7 

ment,  and  the  ligament  in  some  cases  tore  transversely,  in  other 
cases  it  pulled  off  the  tip  of  the  short  arm  of  the  lever  (the  inter- 
nal malleolus).  Ligamentous  resistance  then  being  overcome,  the 
external  surface  of  the  os  calcis  struck  the  tip  of  the  internal 
malleolus,  but  transmitted  no  breaking  force  along  the  fibula.  The 
fibula  broke  because  of  continued  exertion  of  force,  and  usually 
at  a  point  varying  from  two  to  four  inches  from  the  tip  of  the 
malleolus.  When  a  man  breaks  his  fibula,  then,  in  sustaining  a 
Pott's  fracture,  he  breaks  it  after  the  deltoid  ligament  has  lost  its 
hold,  and  because  the  weight  of  the  body  is  then  transferred  from 
the  tibia  to  the  fibula. 

The  common  fracture  near  the  distal  end  of  the  fibula  by  ad- 
duction, on  the  other  hand,  occurs  as  the  result  of  an  entirely 
different  mechanism  from  that  of  Pott's  fracture.  When  the  foot 
of  the  cadaver  was  turned  in  (adducted)  with  a  sufficient  degree  of 
violence,  the  fibula  was  fractured,  usually  a  little  nearer  to  the 
tip  of  the  malleolus  than  in  Pott's  fracture.  Adduction  force 
being  applied,  the  astragalus  rotated  from  within  outward  on  its 
antero-posterior  axis  until  limited  in  its  rotation  by  the  simultane- 
ous impinging  of  its  superior  external  border  against  the  external 
malleolus,  and  of  its  inferior  internal  border  against  the  internal 
malleolus.  In  order  that  rotation  be  continued,  the  two  malleoli 
need  then  an  increased  distance  between  them  ;  but  the  five  liga- 
ments— the  inferior  interosseous,  the  anterior  inferior  interosseous, 
the  anterior  inferior  and  posterior  inferior  tibio-fibular,  and  the 
transverse — prevent  separation  at  the  inferior  tibio-fibular  articu- 
lation, and  consequently,  the  required  space  can  be  gained  only 
through  fracture  of  one  or  both  of  the  bony  barriers  (the  malleoli) 
This  regularly  occurred  in  one,  the  external  malleolus,  or  in  the 
fibula  just  above  the  malleolus,  allowing  the  malleolus  to  be 
pushed  outward  by  rotating  the  astragalus.  Such  was  the  injury 
that  occurred  regularly  in  the  experiments,  but  occasionally  both 
malleoli  snapped  simultaneously  when  forcible  adduction  was 
made,  and  in  such  cases  in  practice,  the  diagnostic  point  for  Pott's 
fracture — tenderness  at  the  inner  side  of  the  ankle — would  not  be 
a  differential  point  unless  we  determined  that  the  point  of  frac- 
ture of  the  internal  malleolus  was  near  the  tibia,  as  it  usually  is  in 
Pott's  fracture,  or  near  the  junction  with  the  shaft,  as  it  usually 
is  in  fracture  of  the  fibula  by  adduction  of  the  foot.  The  patient 
ordinarily  remembers  vividly  whether  the  foot  turned  in  or  out  at 
the  time  of  the  injury.     In  practice,  we  can  pick  out  the  line  of 


1  ;8  Azotes. 


o 


fracture  by  pressing  on  the  skin  over  the  bone  with  the  end  of  a 
lead-pencil.  The  exact  line  of  fracture  can  be  determined  in  this 
way  in  any  bone  that  is  near  the  surface,  the  patient  experiencing 
acute  pain  when  the  end  of  the  lead-pencil  touches  the  skin  over 
the  crack  in  the  bone,  but'^not  when  the  pressure  is  made  a  quar- 
ter of  an  inch  awa}-.  In  fracture  of  the  fibula  by  adduction  of 
the  foot,  when  the  shaft  of  the  fibula  is  broken  at  a  point  suffi- 
ciently far  from  the  malleolus,  the  ends  of  the  fragments  bear 
about  the  same  relation  to  each  other  that  they  do  after 
Pott's  fracture,  and  there  is  a  depression  in  the  soft  parts 
over  the  seat  of  injury.  The  tilting  outward  of  the  external 
malleolus  gives  to  the  front  of  the  ankle  at  the  same  time  a  broad- 
ened appearance.  There  is  little  displacement  of  the  foot  after 
this  fracture  by  adduction,  unless  both  tibia  and  fibula  have  suf- 
fered injury,  but  in  the  latter  case  the  deformity  is  the  same  as 
that  which  accompanies  Pott's  fracture,  the  foot  having  a  ten- 
dency to  remain  in  an  abducted  and  everted  position  by  virtue  of 
the  action  of  the  peroneus  longus  muscle,  and  the  proximal  end 
of  the  distal  fragment  of  the  fibula  usually  lies  to  the  inner  side 
of  the  distal  end  of  the  proximal  fragment  of  the  fibula.  If  there 
is  much  unreducible  deformity  about  the  ankle,  it  is  well  to  cut 
down  upon  and  wire  the  ends  of  the  fragments.  This  I  have  done 
when  the  deformity  was  extreme  in  degree,  for  the  ankle  joint  is 
not  a  good  joint  unless  it  is  a  good  hinge,  and  many  college 
athletes  who  suffer  fracture  near  the  ankle  need  a  perfect  hinge. 
The  proportion  of  fractures  by  adduction  or  by  abduction  is 
shown  in  a  consecutive  series  of  nineteen  cases  which  I  have  pre- 
viously published,  viz. :  six  occurred  by  the  mechanism  of  Pott's 
fracture;  in  two  the  mechanism  was  undetermined  ;  and  the  rest 
suffered  fracture  of  the  fibula  from  adduction  of  the  foot. 


THE  DOWEL-PIN  IN  DISLOCATION  OF  THE  ACROMIAL 
END  OF  THE  CLAVICLE. 

In  two  cases  of  dislocation  at  the  acromial  end  of  the  clavicle  I 
made  a  long  incision  over  the  seat  of  injury,  drilled  the  articular 
surfaces   of   the  acromion   process  and   the  opposed  end   of  the 


/' 


Fig.  52. — Dislocation  of  acromial  end  of  clavicle.      Right  shoulder  broadened 
and  drooping.     End  of  clavicle  projecting  beneath  skin. 

clavicle,  and  inserted  a  stiff  silver  dowel-pin,  about  one  inch  in 
length,  into  the  drill  holes.  The  two  articular  surfaces  were  then 
pushed  together,  and  remained  easily  in  normal  position,  held  by 

139 


140 


Notes. 


the  dowel-pin.  Catgut  sutures  were  used  for  uniting  the  ruptured 
rhomboid  and  trapezoid  h'gaments.  In  one  case,  the  injury  had 
occurred  a  week  previously.  A  photograph  from  this  case  before 
operation,  shows  the  projecting  acromial  end  of  the  clavicle,  and 
the  drooping  and  broadened  right  shoulder.  The  companion 
photograph,  taken  about  eight  weeks  after  operation,  shows  the 
effect  of  repairing  the  shoulder  girdle,  the  shoulder  being  normal 


Fig.  53. — Dislocation  of  clavicle  repaired  by  means  of  dowel-pin. 

in  appearance,  except  for  a  wasting  of  the  trapezius  and  deltoid 
muscles,  which  became  perfectly  normal  two' months  later.  Six 
months  after  the  operation,  although  the  acromio-clavicular  articu- 
lation was  immovably  ankylosed,  this  patient  carried  on  violent 
gymnasium  exercises,  and  took  his  place  in  a  college  boat  crew 
without  further  trouble.  The  movements  of  the  shoulder  are 
only  slightly  limited,  because  the  repaired  shoulder  girdle  is  used 


Dislocation  of  the  Clavicle.  141 

as  a  Avhole  more  freely  than  the  left  one.  In  the  other  case,  which 
was  a  dislocation  of  the  left  clavicle  and  of  lonj^  standing,  there 
was  a  complication  consisting  of  a  fracture  of  the  clavicle  near  the 
acromial  end,  which  had  united  in  a  somewhat  angular  position. 
In  this  case,  a  shoulder  without  deformity,  excepting  for  the  frac- 
ture angle,  was  obtained.  There  is  firm  ankylosis  but  some  disa- 
bility, the  arm  not  being  quite  as  strong  as  the  right  one,  although 
perfectly  useful  for  all  ordinary  purposes.  Nearly  a  year  Was 
required  for  restoring  the  wasted  trapezius  and  deltoid  muscles 
to  a  normal  condition,  by  the  use  of  massage,  electricity,  and 
strychnine  injections  in  this  second  case. 


THE  DOWEL-PIN  IN  FRACTURE  OF  THE  CLAVICLE. 

'The  dowel-pin  was  employed  in  one  of  my  cases  of  fracture  of 
the  clavicle,  and  this  resource  will  be  of  value  in  other  cases  in 
which  deformity  is  particularly  to  be  avoided,  as  in  cases  of  fracture 
of  the  clavicle  in  young  women. 

In  the  case  in  question,  an  oblique  fracture  at  the  junction  of 
the  outer  and  middle  thirds  of  the  left  clavicle  of  a  muscular  man 
would  not  permit  of  retention  of  the  fragments  in  position.  An 
impromptu  dowel-pin  was  made  from  the  silver  bar  of  a  watch. 
chain.  An  incision  not  more  than  an  inch  in  length  was  made 
through  the  skin.  The  outer  fragment  of  the  clavicle  was  first 
lifted  with  narrow  volsella  forceps,  and  the  dowel-pin  having  been 
pushed  for  half  its  length  into  the  cancellous  structure  of  this 


Fig.  54. — Dowel-pin  in  fractured  clavicle. 


fragment,  the  projecting  remaining  half  of  the  pin  was  allowed  to 
sink  into  a  little  slot  cut  into  the  anterior  surface  of  the  other 
fragment  with  a  small  chiseL  The  wound  healed  by  primary 
union,  and  at  the  end  of  four  weeks  the  patient  resumed  the  free 
use  of  his  arms  in  his  work  as  a  laborer.  There  was  not  the 
slightest  trace  of  deformity,  and  the  scar  was  barely  apparent.  A 
skin  incision,  half  an  inch  in  length,  would  have  answered  for  this 
operation.  An  evanescent  scar  can  be  obtained  in  such  cases  by 
the  technique  which  is  employed  for  obtaining  such  a  scar  in  an 
appendicitis  operation.  (See  description  of  this  technique  under 
Appendicitis.) 

142 


MALLET-FINGER. 

The  deformity  here  described  is  not  uncommon  among  men 
who  engage  in  athletic  sports. 

When  the  extensor  tendons  of  the  fingers  are  tense,  a  blow 
upon  the  end  of  a  finger  transmitting  force  in  a  direction  w^iich 
would  ordinarily  flex  the  finger,  results  in  injury  to  the  extensor 
tendon  in  the  vicinity  of  its  attachment  to  the  dorsal  surface  of 
the  last  phalanx.  The  injury  consists,  not  in  a  bodily  separation 
of  the  tendon  from  its  points  of  attachment,  but  rather  in  a  thin- 
ning of  the  tendon  proximally  from  the  principal  point  of  attach- 


FlG.  55. — Mallet-finger.      Permanent  flexion  of  tip  of  index-finger. 


ment  to  the  phalanx,  and  from  the  fibres  that  form  the  posterior 
ligament  of  the  last  pharyngeal  articulation.  A  few  fibres  of  the 
tendons  are  undoubtedly  ruptured,  but  most  of  them  slide  away 
from  each  other  very  much  as  the  threads  of  a  textile  fabric  sepa- 
rate when  the  fabric  is  violently  stretched,  but  not  torn,  the  struc- 
ture retaining  its  original  general  appearance. 

Immediately  after  the  occurrence  of  the  injury  to  the  tendon 
the  last  phalanx  of  the  finger  assumes  a  semi-flexed  position,  and 
the  deformity  is  usually  permanent,  the  extensor  tendon  then 
having  little  or  no  influence  upon  the  freed  phalanx.  Aside  from 
the  uncanny  appearance  of  such  a  finger,  the  deformity  is  a  source 
of  much  annoyance  to  the  patient. 

143 


144 


Noii 


^s. 


The  tendon  is  repaired  without  much  difficulty  by  making  a 
longitudinal  incision  two  centimetres  in  length  over  the  site  of 
the  injury,  dividing  the  thinned  tendon  longitudinally  into  the  two 
principal  fasciculi  into  which  it  naturally  separates,  dividing  the 


Fig.  56. — Extensor  tendon  of  index-finger  tliinned  at  point  of  attachment  by   arti- 
ficial production  of  mallet-finger  upon  the  cadaver. 

tendon  transversely,  proximally  from  the  thinnest  point,  and  ad- 
vancing each  fasciculus  to  a  point  upon  its  own  side  of  the  finger, 
near  the  base  of  the  finger-nail.  At  this  point  the  fasciculus  is 
sutured  to  the  under  surface  of    the  skin  with  a    suture  which 


Fig.  57. — End  of  index-finger,  showing  line  of  incision  and  sutures.      Two  black  dots 
mark  sutures  uniting  fasciculi  and  skin. 


passes  through  the  skin  and  is  tied  upon  the  outside.  The  fas- 
ciculi are  sutured  to  skin  rather  than  to  periosteum  and  tendinous 
remains,  because  the  former  structure  affords  a  firmer  hold  and 
the  cut  end  of  the  tendon  makes  as  good  union  with  the  phalanx 
as  it  would  if  sutured  directly  to  periosteum. 


Fracture  of  iJie  Clavicle. 


H5 


The  finger-nail  is  sometimes  lost  temporarily  as  a  result  of  the 
■operative  disturbance  near  its  matrix. 

When  the  advanced  fasciculi  are  sutured  in  place  there  is  an 
over-correction   of  the  deformity  of    the    phalanx,    which    causes 


Tig.  58. — Temporary  flexion  at  middle  phalangeal  articulation  after  advancement  of 

extensor  tendon. 


also  a  flexion  at  the  middle  phalangeal  articulation.  This  condi- 
tion is  temporary,  and  disappears  spontaneously  in  a  few  weeks, 
leaving  a  perfect  finger. 


TWO  CASES  OF  CONSERVATIVE  SURGERY  OF  THE  ARM. 


A  YOUNG  woman,  twenty  years  of  age,  caught  her  fingers  between  hot 
rollers  in  a  laundry  and  the  right  hand  and  arm  were  drawn  into  the 
machine  and  destroyed  to  the  bone  wherever 
the  tissues  were  held  in  contact  with  the  rollers. 
The  structures  that  escaped  were  three  fingers 
and  about  one  fifth  of  the  liand,  a  narrow  strip 
of  skin  along  the  ulna,  barely  an  inch  wide,  and 
the    tissues  between  that  strip  of  skin  and  the 


\ 


Fig.  5g. — Burned  and  sphacelated 
hand  and  arm. 


Fig.  6o. — Sphacelated  region 
excised. 


interosseous  ligament,  carrying    the  posterior  interosseous  artery.     All 
other  structures  were  destroyed,  and  they  sloughed  away  for  the  greater 

146 


Conservative  Surgery  of  the  Ann. 


147 


part  leaving  the  bones  of  the  forearm  and  wrist  bare.  Where  the 
burned  tissues  did  not  slough  away  they  dried  and  clung  to  the  bone. 
There  was  no  sensation  below  the  proximal  portion  of  the  spared  strip 
of  skin  along  the  ulna.  I  excised  the  destroyed  parts  by  cutting  away 
the  dried  forefinger  and  thumb,  and  sawing  transversely  through  all  of 
the  metatarsal  bones  at  the  distal  portion  of  the  injury,  and  through  the 
radius  and  ulna  at  the  proximal  end  of  the  injury,  being  careful  to  lift 
the  strip  of  skin  and  the  tissues  carrying  the  interosseous  artery  out 
of  the  way  before  excising  the  bones.  The  soft  parts  at  the  lines  of 
excision    were  cut  transversely  across,  and  very   neatly,   in  order  to 


Fig.  61. — Fingers  transplanted  to  arm.       Loop  carrying  interosseous  artery. 


ensure  good  union  of  tissues  if  the  small  arterial  connection  should 
prove  equal  to  the  task.  The  portion  of  hand  bearing  the  three  living 
fingers  was  then  carried  up  to-  the  stump  of  arm,  and  ends  of  meta- 
carpal bones  were  placed  in  contact  with  the  ends  of  radius  and  ulna. 
The  flexor  tendon  of  the  third  finger  was  sutured  to  the  flexor  carpi 
radialis  muscle.  The  flexor  tendon  of  the  fourth  finger  was  sutured  to 
palmaris  longus.  The  flexor  tendon  of  the  fifth  finger  was  sutured  to 
flexor  carpi  ulnaris.  The  reason  why  these  connections  were  made 
instead  of  the  natural  ones  was  because  I  had  to  choose  the  most  useful- 
looking  structures  of  the  arm  stump,  and  selected  muscles  in  which 
tendinous  bands  gave  prospect  of  forming  a  union  with  finger  tendons. 
The   extensor  tendons  of  the  fingers  were  sutured  to  various  fascial 


148 


Notes. 


bands,  there  being  little  opportunity  to  make  definite  connections. 
When  the  fingers  had  thus  been  sutured  to  tlie  arm  the  ribbon  of 
tissue  carrying  the  interosseous  artery  stood  out  in  the  form  of  a  loop 
several  inches  high.  All  skin  margins  were  sutured  and  the  loop  of 
tissue  was  loosely  packed  in  gauze  in  such  a  way  as  to  avoid  compres- 


FiG.  62. — Repair  completed.    Both  arms  placed  ^de  by  side  for  comparison. 
From  photographs  seve'ral  months  after  operation. 


sion  or  angulation.  The  dressing  applied  was  the  customary  permanent 
one.  The  entire  wound  healed  by  primary  union  under  this  one 
dressing,  and  about  two  months  later  I  cut  avvay  the  loop  carying  the 
artery,  having  first  determined  that  the  fingers  showed  signs  of  circula- 
tion of  blood  while  the  loop  was  compressed  firmly  to  cut  off  circulation 
by  that  route.  I  had  not  expected  that  sensation  would  return  in  the 
fingers,  but  believed  that  the  fingers  would,  nevertheless,  be  more  use- 


Consci'vative  Surgery  of  the  Arm.  149 

ful  than  an  artificial  hand.  Sensation  began  to  appear,  however,  in  the 
fingers  about  three  months  after  the  operation,  and  the  ability  to  dis- 
tinguish heat  from  cold,  the  patient  thinks,  returned  simultaneously 
with  the  sense  of  touch.  Sensation  began  first  in  the  little  finger,  and 
four  months  from  the  date  of  operation  it  seemed  to  be  almost 
normal  in  degree  in  all  of  the  fingers.  The  patient  with  eyes  closed 
could  not  tell  instantly  which  finger  or  what  part  of  a  finger  was 
touched  or  pricked,  although  the  sensation  was  instantly  transmitted  to 
the  brain.  Several  seconds  later  she  could  localize  the  point  at  which 
contact  was  being  made.     The  nails  of  the  three  fingers  grew  normally. 

i 


Fig.  63. — Destruction  of  tissues  of  right  arm. 

The  flexor  tendons  made  excellent  connection  at  their  points  of  suture, 
but  the  extensor  tendons  made  a  feeble  connection,  so  that  the  fingers 
remained  flexed,  but  could  be  voluntarily  extended  a  little  en  masse. 
Flexion  was  strongly  made  en  masse,  but  the  patient  could  not  dis- 
tinctly move  each  finger  separately.  Flexion  could  be  made  with  suffi- 
cient degree  of  force  to  hold  the  handle  of  a  brush  or  comb  or  knife, 
and  the  fingers  were  useful  enough  for  such  purposes,  but  the  patient 
was  a  sensitive  girl  who  was  so  much  mortified  at  the  interest  shown  in 
her  uncanny  deformity  by  friends  and  by  strangers  that  she  begged  to 
have  the  fingers  amputated  so  that  she  could  wear  a  false  arm  and  hand 
that  would  look  more  attractive.  With  much  regret  I  complied  with 
her  demand  about  a  year  later  and  amputated  through  the  stump  of  the 


i50 


Notes. 


arm  on  the  proximal  side  of  the  scar,  preserving  in  the  specimen  all  of 
the  connections  that  had  been  made  between  united  tendons  and 
nerves.  I  have  not  felt  sufficiently  expert  to  make  such  a  dissection  of 
the  specimen  as  it  deserves,  and  await  the  request  of  some  anatomist 
It  whose  disposal  it  can  be  placed. 


\ 


Fig.   64. — Arm  repaired.      Both    arms    placed     together    for    comparison, 
photograph  several  years  after  operation. 


From 


In  another  case  a  youth  about  fifteen  years  of  age  caught  his  right 
arm  between  a  belt  and  a  swiftly  revolving  wheel  -which  almost  com- 
pletely destroyed  the  involved  portion  of  the  arm  (Fig.  d-^.  Splintering 
the  radius  and  ulna,  tearing  away  soft  structures,  and  leaving  a  narrov/ 
strip  of  tissue  which  carried  the  ulnar  artery  intact,  but  which  was 
ground  full  of  oil  and  shop  dirt.  More  than  two  hours  of  time  were  re- 
quired for  trimming  and  uniting  injured  structures,  and  an  inch  or  more 
of  ulna  had  to  be  resected  later  at  a  second  operation.  Although  the 
injured  arm  is  crooked,  and  four  inches  shorter  than  its  fellow,  it  is 
practically  a  normal  arm,  and  with  it  the  patient  plays  the  violin  and 
does  all  ordinary  work.  If  I  had  resected  an  extra  inch  of  the  radius 
and  ulna  at  the  first  operation,  non-union  of  the  ulna  would  have  been 
avoided  and  the  arm  would  not  have  been  crooked. 


SKIN    GRAFTING   FROM   BLISTERS. 

Skin  grafts  for  application  according  to  the  method  of  Thiersch 
may  be  obtained  from  bhsters.  The  idea  of  using  grafts  of  this 
sort  first  occurred  to  me  while  treating  burns  in  which  large  blebs 
had  formed.     After  securing  and  cleansing  the  separated  cuticle 


t^i 


^ 


7 


/    -1? 


1  -l 


/     i 


Fig.  65. — A.   Blister.       B.   Gutta-percha  tissue  for  making 
a  roll  with  separated  cuticle. 

in  physiological  saline  solution  it  was  replaced  upon  the  sterilized 
wound  where  it  adhered  well  in  cases  in  which  the  skin  had  not 
been  subjected  to  a  destructive  degree  of  heat.     Since  that  time 

151 


1 5  2  Notes. 

I  have  obtained  blister  grafts  and  have  applied  them  successfully 
to  small  wounds.  The  new  epithelium  which  covers  the  site  of  a 
blister  graft  is  more  delicate  than  a  Thiersch  graft  covering,  and 
consequently  is  not  so  desirable  for  large  wounds.  Sometimes 
the  blister  graft  does  not  become  adherent,  but  conducts  new 
epithelium  across  the  wound  so  rapidly  that  repair  is  completed 
under  one  dressing,  in  cases  which  would  otherwise  require  several 
weeks  for  granulation.  My  plan  of  procedure  consists  in  steriliz- 
ing the  skin  from  which  a  graft  is  to  be  taken,  and  then  raising  a 
blister  of  the  desired  shape  and  size  with  cantharides.  The  blister 
cuticle  is  snipped  away  by  cutting  around  its  margins.  A  piece 
of  gutta-percha  tissue  is  laid  upon  the  graft  and  gutta-percha  and 
graft  are  rolled  up  together,  making  a  compact  roll  which  is  easily 
handled.  The  graft  is  then  transferred  to  the  wound  and  un- 
rolled upon  it,  leaving  the  gutta-percha  tissue  in  place.  The 
preparation  of  the  wound,  and  the  after-treatment,  are  conducted 
according  to  Thiersch's  method,  bearing  well  in  mind  the  fact 
that  any  chemical  antiseptics  which  have  been  employed  for  ster- 
ilizing the  wound  must  be  removed  by  flushing  with  physiological 
saline  solution  before  the  graft  is  applied.  The  gutta-percha 
tissue  is  not  removed  from  the  graft  for  ten  days  or  two  weeks^ 
but  sometimes  the  outer  dressing  will  need  changing  if  it  becomes 
too  dry  and  hard.  An  attached  blister  graft  sometimes  becomes 
several  times  thicker  than  the  cuticle  at  the  time  when  it  was 
transplanted,  but  I  have  not  as  yet  made  a  microscopic  section  of 
such  thickened  tissue  to  determine  the  nature  of  its  structure. 


PHELPS'  HARE-LIP  OPERATION  IN  TWO  STEPS. 

The  prettiest  hare-lip  operation  with  whicli  I  am  familiar  is  that 
of  Dr.  Phelps,  which  places  the  scar  in  the  middle  line  of  the  lip, 
with  no  deviation  of  any  part  of  the  scar  to  either  side  of  the  middle 
line.  This  result  is  accomplished,  if  the  fissure  is  to  the  right  of 
the  middle  line,  by  making  another  similar  fissure  to  the  left  of  the 
middle  line  with  a  pair  of  scissors,  and  then  cutting  out  the  inter- 
vening tissues  between  the  two  fissures,  and  joining  the  walls  of 
the  fissures  in  the  middle  line.  It  is  a  case  in  which  two  equal 
wrongs  make  one  right.  A  "  V  "  of  lip,  with  its  base  at  the  sep- 
tum of  the  nose,  can  be  saved  if  we  wish,  when  the  piece  of  lip 
between  the  two  fissures  is  cut  out. 

Because  of  the  loss  of  tissue  in  the  Phelps  operation,  it  is  un- 
fortunately confined  to  a  comparatively  small  proportion  of  cases, 
making  too  flat  a  lip  in  cases  which  require  removal  of  much  tissue, 
but  I  have  made  it  applicable  to  a  larger  class  by  first  repairing  a 
hare-lip  fissure  by  the  old-fashioned  straight-line  method,  and  then 
waiting  a  few  months  to  allow  the  orbicularis  muscle  to  draw  the 
scar  nearer  to  the  middle  line,  as  it  may  be  expected  to  do.  The 
scar  will  very  often  be  drawn  to  a  point  not  more  than  one  fourth 
of  the  distance  from  the  middle  line  of  the  lip  to  the  angle  of  the 
mouth  on  that  side,  and  then  the  second  fissure  can  be  made  and 
the  scar  placed  in  the  middle  line.  There  are  very  many  patients 
about  the  country  who  are  carrying  hare-lip  scars  that  are  a  source 
of  mortification  to  them,  but  whose  scars  can  be  placed  in  the 
middle  line  where  they  will  not  attract  attention.  The  cheeks 
should  be  well  loosened  from  their  attachments  to  the  superior 
maxillary  bone  if  we  wish  to  have  the  orbicularis  muscle  take  up 
enough  of  the  lower  lip  to  lengthen  a  short  repaired  upper  lip. 
New  angles  of  the  mouth  will  then  form. 

At  this  point  I  will  add  a  note  on  another  plastic  operation 
which  has  no  connection  with  hare-lip.  One  of  my  repaired  noses 
could  not  be  supported  because  there  was  no  septum.  A  most  ex- 
cellent septum  was  made  by  turning  up  a  large  flap  of  lip,  extend- 
ing from  the  nose  to  the  mouth,  and  suturing  it  to  the  interior  of 

153 


154  Notes. 

the  nose  where  the  septum  was  needed.  The  margins  of  the 
wound  of  the  Hp  were  then  united,  just  as  they  are  after  the  mid- 
line hare-lip  operation.     The  septum  is  satisfactory  in  this  case. 


DISTENSION  OF  FISTULOUS  PIPES  WITH  PLASTER  OF 
PARIS  TO  FACILITATE    THEIR  REMOVAL. 

In  several  of  my  cases  of  fistula  in  ano,  and  in  one  case  of  long, 
tortuous  fistula  of  the  plantar  region,  plaster  of  Paris  was  injected  into 
the  fistulous  tracts,  and  allowed  to  set.  Guided  by  the  rigid  plaster,  it 
was  then  an  easy  matter  to  dissect  out  a  fistulous  pipe  in  its  entirety, 
and  muscles  which  were  divided  in  following  the  pipe  were  closely 
sutured  for  primary  union.  Plaster  of  Paris  will  not  set  if  any  pus  or 
blood  remain  in  the  fistulous  tract,  and  the  resource  cannot  be  applied 
except  in  cases  in  which  we  can  perfectly  cleanse  the  tract  first  with 
peroxide  of  hydrogen  and  saline  solution.  After  this  has  been  done,  a 
small  glass  syringe  is  loaded  with  well  salted  plaster,  prepared  as  for 
making  a  cast,  and  before  the  plaster  begins  to  thicken  the  contents  of 
the  syringe  are  injected  forcibly  into  the  fistula,  pressing  the  nozzle  of 
the  syringe  closely  against  one  opening,  and  closing  any  other  opening 
with  the  end  of  the  finger.  The  syringe  and  the  finger  which  closes 
the  opening  must  be  kept  in  place  for  a  few  minutes  until  the  plaster 
has  set.  The  time  can  be  determined  by  watching  any  plaster  which 
remains  in  the  syringe.  The  syringe  is  then  thrown  away,  and  the  pipe, 
distended  with  a  very  hard  core  of  plaster,  is  dissected  out. 

It  is  not  necessary  to  apply  this  resource  in  most  of  our  cases  of 
fistula,  but  it  is  sometimes  very  useful. 


PREVENTION  OF  ABORTION  BY  REMOVAL  OF  A 
UTERINE  FIBROID. 

A  PATIENT  thirty-two  years  of  age  in  the  fourth  month  of  her  first 
pregnancy  began  to  have  symptoms  of  a  threatened  abortion,  uterine 
contractions  occurring  at  intervals  of  about  fifteen  minutes.  Opium, 
hot  fomentations,  and  posture  failed  to  stop  the  symptoms.  On  exami- 
nation by  palpation  -through  the  abdominal  walls  I  found  a  sessile 
subperitoneal  uterine  fibroid  about  as  large  as  a  man's  fist  situated  upon 
the  fundus  of  the  uterus  near  the  right  oviduct.  The  abdomen  was 
opened,  and  the  tumor  removed  by  enucleation.  The  wound  in  the 
uterus,  about  five  inches  in  length,  but  not  penetrating,  was  closed  with 
a  continuous  suture  of  catgut.  Uterine  contractions  ceased  at  once, 
and  a  normal  child  was  born  at  full  term. 


Inversion  of  the  Utertis.  i  5  5 

REDUCTION  OF  AN  INVERTED  UTERUS  BY  INCISING 
THE  CONSTRICTING  RING  INTRA-ABDOMINALLY. 

A  PATIENT,  twenty-four  years  of  age,  had  a  complete  inversion  of  the 
uterus  after  parturition.  Packing  of  the  vagina  for  two  months,  by  the 
family  physician,  had  allowed  good  involution  to  take  place,  but  it  was 
found  to  be  impossible  to  relieve  the  inversion  by  way  of  the  vagina,  I 
made  an  abdominal  incision  in  order  to  effect  reduction  bimanually  and 
by  internal  dilatation  of  the  constricting  cervix.  This  failing,  the  en- 
trapped bladder  and  uterine  adnexa  were  drawn  out  of  the  way,  and 
the  uterine  wall  and  the  ring  of  cervix  were  divided  with  a  long  scalpel. 
The  inversion  was  then  easily  reduced.  I  had  been  tempted  to  divide 
the  constriction  from  the  vaginal  side,  but  when  the  abdomen  was 
opened  it  was  observed  that  the  bladder  or  vessels  of  the  broad  liga- 
ment w^ould  have  been  cut  if  that  procedure  had  been  attempted. 


HYSTERECTOMY  FOR  PLACENTA  PREVIA. 

A  WOMAN,  thirty-four  years  of  age,  in  the  fifth  month  of  pregnancy, 
suddenly  had  an  alarming  hemorrhage  from  the  uterus,  which  stopped 
spontaneously,  with  the  exception  of  a  little  oozing.  On  examination  it 
was  determined  that  one  margin  of  the  placenta  was  apparently  so  near 
the  cervical  region  that  it  had  become  separated  through  unequal 
expansion  of  the  uterus,  although  the  case  was  not  one  of  well  marked 
placenta  previa.  I  planned  to  dilate  the  cervix  rapidly,  and  get  past 
the  placenta  in  time  to  deliver  the  child  before  hemorrhage  could  prove 
fatal,  but  one  of  the  consultants  had  been  present  at  two  deaths  result- 
ing from  this  plan  of  management.  In  both  cases  an  attempt  was 
made  to  hold  the  separated  margin  of  placenta  against  the  uterine  wall 
with  a  finger  in  order  to  stop  hemorrhage  by  compression  while  dilata- 
tion was  being  effected,  but  in  both  cases  the  blood,  thus  being 
prevented  from  escaping,  instantly  dissected  off  the  whole  placenta, 
and  the  patients  died  on  the  table.  I  feared  to  dilate,  but  knew  that 
abdominal  hysterectomy  w^ould  be  a  safe  procedure,  and  this  was  con- 
sequently done,  the  uterus  with  its  contained  fetus  being  removed  in 
one  mass.     The  patient  recovered  without  complications. 


OVARIAN  TRANSPLANTATION. 

Ix  the  hope  of  putting  a  stop  to  the  sacrifice  of  uteri  in  cases 
in  which  the  adnexa  must  be  removed,  and  in  the  attempt  to 
make  useful  organs  out  of  uteri  with  congenitally  rudimentary 
adnexa,  I  began  experimentation  in  1895  by  the  plan  of  trans- 
planting a  segment  of  normal  ovary  from  one  woman  to  the 
fundus  of  the  uterus,  or  to  the  oviduct,  of  another  woman. 

In  another  class  of  cases  in  which  the  adnexa  had  been  ren- 
dered useless  by  disease,  but  in  which  a  portion  of  at  least  one 
ovary  remained  good,  I  have  transplanted  that  piece  of  ovary 
into  the  patient's  own  uterus  or  oviduct.  The  procedure  was 
thought  to  be  rational,  judging  from  the  known  fact  that  a  seg- 
ment of  thyroid  gland  will  continue  to  do  its  functional  work 
after  transplantation  to  a  remote  part  of  the  body.  Out  of  five 
transplantations  made  to  date  I  have  obtained  two  results,  one 
of  which  gives  definite  evidence  that  a  transplanted  segment  of 
ovary  can  form  ova. 

Case  i. — Mrs.  J.  F.,  Jr.,  aged  twenty-six  years,  not  pregnant  in  two 
years  of  married  life.  Septic  tubal  disease  of  long  standing  had  prac- 
tically obliterated  the  ovaries  and  tubes,  leaving  the  pelvis  filled  with 
dense  adhesions.  Chronic  metritis.  Remnants  of  tubes  and  ovaries 
removed,  together  with  masses  of  pyogenic  tissue.  A  small  piece  of 
the  patient's  diseased  ovary  was  transferred  to  the  interior  of  the  stump 
of  the  right  oviduct  (saline  solution  transmission).  The  patient 
became  pregnant  shortly  after  leaving  the  hospital  about  a  month 
later,  but  lost  a  well  developed  fetus  by  abortion  at  the  third  month, 
presumably  because  of  the  presence  of  persistent  pelvic  adhesions. 
This  result  means  that  we  are  to  be  very  conservative  in  the  treatment 
of  some  of  the  uteri  which  gynecologists  are  at  present  wishing  to 
remove  on  the  ground  that  such  uteri  are  useless  because  the  adnexa 
have  been  removed.  It  means  also  that  we  should  hunt  up  some  of 
our  old  patients  whose  adnexa  have  been  removed,  and  give  them  the 
benefit  of  a  graft  of  new  ovary,  in  the  possibility  of  relieving  them  from 
the  condition  of  barrenness. 

Case  2. — Miss  L.  B.,  aged  twenty  years.     Infantile  uterus  and  rudi- 

156 


Ovarian    Trajisplantaiion.  157 

mentary  adnexa.  Had  never  menstruated.  Suffered  from  the  common 
symptoms  of  suppression  of  menstruation.  Received  an  ovarian  graft 
in  the  fundus  of  the  uterus  from  the  ovary  of  a  patient  aged  about 
thirty  years.  Eight  weeks  later  menstruated  for  the  first  time  in  her 
life  ;  menstruation  profuse,  lasting  for  ten  days.  Second  menstruation 
six  weeks  later,  lasting  for  five  days,  and  normal  in  character.  Third 
menstruation  five  weeks  later  ;  scanty  and  lasting  for  one  day. 
Fourth  and  fifth  menstrual  periods  at  intervals  of  four  weeks,  and 
normal  in  character.  I  do  not  know  how  much  significance  is  to  be 
attached  to  this  result,  as  any  form  of  operative  procedure  upon  the 
uterus  might  perhaps  have  stimulated  the  uterine  sympathetic  nerves  to 
a  performance  of  the  function  of  menstruation.  The  patient  has  made 
a  great  change  for  the  better  in  personal  appearance,  and  is  relieved 
from  her  former  distress. 

In  transplanting  ovary  from  one  woman  to  another  there  is 
abundant  opportunity  in  hospital  practice  where  it  is  not  difificult 
to  arrange  for  operation  upon  two  patients  in  the  same  hour, 
and  one  woman  whose  ovaries  contain  normal  tissue  can  spare 
for  the  other  woman  a  segment  of  ovary  as  large  as  a  pea  without 
suffering  any  real  loss.  The  method  which  I  have  found  to  be 
best  consists  in  removing  from  the  normal  ovary  a  segment  about 
as  large  as  a  pea  and  placing  it  in  warm  physiological  saline  solu- 
tion, temporarily.  The  fundus  of  the  uterus  that  is  to  receive 
this  piece  of  ovary  is  then  split  transversely  down  to  the  lumen. 
The  piece  of  ovary  is  introduced  into  the  slit  in  the  uterus  in 
such  a  way  that  peritoneal  surface  of  ovary  will  rest  against  endo- 
metrium of  uterus  and  raw  surface  of  ovary  remains  in  contact 
with  raw  surface  of  uterus,  and  is  fastened  in  place  by  a  fine  cat- 
gut suture  that  serves  at  the  same  time  to  partially  close  the  slit 
in  the  uterus.  Other  sutures  that  are  necessary  for  closing  the 
wound  are  introduced,  and  a  drainage  wick  of  gauze  is  placed  in 
the  uterine  canal  leading  out  through  the  vagina  into  a  receiving 
mass  of  gauze  at  the  vulva.  The  fundus  of  the  uterus  that  is  to 
receive  a  graft  is  reached  by  way  of  an  anterior  abdominal  inci- 
sion, or  preferably  by  way  of  the  vagina  through  a  button-hole 
opening  into  Douglas'  ciil  de  sac.  The  fundus  is  readily  turned 
down  into  the  vagina,  and  after  receiving  the  graft  is  turned  back 
into  the  abdomen  again,  and  the  patient  is  then  ready  to  get  out 
of  bed  in  two  or  three  days.  The  gauze  drain  from  the  uterus  is 
removed  at  the  end  of  forty-eight  hours  after  the  operation  and 
the  case  should  require  little  further  treatment. 


i=;S 


Notes. 


In  cases  in  which  the  oviduct  is  chosen  as  the  place  for  insert- 
ing an  ovarian  graft,  it  is  difficult  to  find  the  lumen  of  the  tube 


Fig.  66. — A. — Suture  of  slit  through  which  graft  was  inserted. 
B. — Ovarian  graft. 
C. — Drainage  wick. 


Ovarian  Transplantation. 


159 


if  the  latter  has  been  cut  short,  because  the  muscular  sheath  con- 
tracts and  inverts  margins  of  the  mucous  tube.  Before  attempt- 
ing to  insert  the  graft  in  such  a  case  it  is  best  to  pass  a  probe 
through  the  lumen  of  the  oviduct  into  the  uterus  first  and  then 
amputate  the  oviduct  about  the  probe,  suturing  mucosa  and 
peritoneum  together  at  any  one  point  in  the  circular  cut  before 
completing  the  division.  This  will  prevent  inversion  of  mucosa 
when  the  muscularis  contracts  and  will  allow  us  to  keep  the  graft 


Fig.  67. — A. — Peritoneum  of  oviduct. 
B. — Muscularis. 
C. — Mucosa. 
D. — Lumen. 

E. — Segment  of  transplanted  ovary. 
F. — Suture  for  holding  segment  of  ovary. 
G. — Suture  for  keeping  mucosa  and  serosa  together. 
H. — Suture  for  closinsr  end  of  oviduct. 


in  contact  with  mucosa  later  on  so  that  ova  can  escape  into  the 
lumen  of  the  oviduct.  The  next  step  consists  in  dilating  the 
stump  of  oviduct  up  to  the  point  of  paralysis  of  its  muscularis  so 
that  further  work  can  be  done  more  easily.  The  segment  of 
ovary  that  is  to  be  engrafted  is  then  taken  out  of  the  warm  saline 
solution  and  its  raw  surface  is  sutured  with  one  strand  of  finest 
catgut  to  the  raw  surface  of  the  oviduct  in  such  a  way  that  these 
two  raw  surfaces  will  adhere  to  each  other  and  allow  normal  sur- 


1 60  Notes. 

face  of  ovary  to  project  into  the  lumen  of  the  oviduct  when  the 
final  step  is  taken  of  closing  the  abdominal  end  of  the  oviduct. 

Some  patients  object  to  the  idea  of  carrying  a  piece  of  ovary 
from  another  woman,  as  the  child  from  such  a  case  would  have 
treble  parentage,  but  there  are  many  women  whose  uterine 
adnexa  have  been  removed  who  grasp  at  an  opportunity 
for  bearing  children,  and  whose  minds  are  much  relieved  at  the 
thought  of  the  possibility  of  such  a  prospect.  It  is  not  improb- 
able that  menstruation  and  normal  sexual  impulse  may  continue 
in  women  who  carry  an  ovarian  graft,  and  I  shall  obtain  full 
testimony  bearing  upon  this  point.  It  will  be  interesting  to 
know  which  half-mother  the  child  from  an  ovarian  graft  will 
resemble,  and  there  may  be  legal  difficulties  involved  in  questions 
of  inheritance. 


HEALING  THROUGH  THE  AGENCY  OF  BLOOD  CLOT. 

Several  authors,  previous  to  the  year  1883,  had  noted  that 
blood  clots  in  certain  aseptic  wounds  did  not  decompose,  but 
became  replaced  by  connective  tissue.  Acting  upon  this  knowl- 
edge I  began  experimentation  in  the  intention  of  purposely 
applying  blood-clot  replacement  as  a  surgical  resource.  Several 
difificulties  had  to  be  overcome.  I  found,  in  the  first  place,  that 
if  gauze  or  cotton  came  in  contact  with  the  clot,  so  much  serum 
was  abstracted  that  the  mass  of  fibrin  became  too  hard  and  the 
clot  was  rejected  by  granulations.  It  was  observed  later  that  if 
carbolic  acid  solution  came  in  contact  with  a  wound,  the  contained 
clot  became  blackish  and  friable.  Gutta-percha  tissue  was  a 
failure  as  a  protection  for  clots,  because  it  was  wholly  imper- 
vious to  moisture,  and  it  caused  the  retention  of  an  excess  of 
serum  which  macerated  the  coagulum.  After  much  experimen- 
tation I  finally  observed  that  very  thin  protective  oiled  silk  was 
the  needful  thing  for  success,  and  under  this  dressing  a  clot 
further  protected  by  a  permanent  antiseptic  dressing  would 
entirely  fill  an  open  wound,  and  would  become  replaced  by  con- 
nective tissue  and  covered  with  epithelium  in  a  few  days.  At 
first,  clot  replacement  was  employed  in  small  open  wounds 
involving  bone  cavities,  and  in  depressed  scars,  which  were  dis- 
sected loose  by  subcutaneous  incision  and  then  allowed  to  bulge 
over  a  clot,  but  in  the  autumn  of  18S4,  while  visiting  the  clinic 
of  Dr.  Max  Schede,  I  persuaded  Dr.  A.  M.  Phelps  to  apply  the 
clot-replacement  resource  in  a  series  of  open-incision  club-foot 
operations  that  he  had  been  invited  to  perform  at  the  clinic. 
The  results  were  so  satisfactory  that  Dr.  Schede,  ever  alert  for 
surgical  respurce's,  immediately  began  to  apply  the  method  in  a 
large  variety  of  cases,  and  in  the  Deutsche  medicinische  WocJien- 
scJirift  for  June,  1886,  he  was  enabled  to  publish  a  report  upon 
240  cases',  in  which  222  wounds  healed  by  blood-clot  replacement 
without  suppuration. 


161 


SUBSEQUENT  NOTES  ON  APPENDICITIS. 

In  response  to  inquiries  about  later  statistics,  I  began  with  case 
30,  on  page  32,  and  added  from  my  record  books  thirty  consecu- 
tive cases  following  case  lOO,  on  page  80.  This  made  a  series  of 
one  hundred  consecutive  appendicitis  operations,  the  details  of 
which  were  presented  in  a  paper  read  at  a  meeting  of  the  New 
York  Academy  of  Medicine  on  February  10,  1896,  showing  a 
death-rate  of  two  per  cent.  All  of  the  patients  were  of  the 
private-patient  class,  and  could  be  kept  under  observation  by 
their  respective  physicians.  Adhesion  complications  have  been 
the  principal  ones  reported.  There  is  one  case  of  paralysis  of  the 
right  rectus  abdominal  muscle,  but  no  case  of  ventral  hernia. 
The  two  deaths  on  the  list  were  unnecessary,  and  could  have 
been  avoided  by  observance  of  the  rule  to  operate  in  advance  of 
abscess  formation.  For  the  results  shown  in  this  series  of  cases 
I  make  no  claim  to  the  employment  of  any  special  skill  beyond 
the  simple  application  of  resources  with  which  all  surgeous  have 
become  more  or  less  familiar  of  late  years.  The  death-rate  how- 
ever would  have  been  largely  increased  if  I  had  used  resources 
which  are  employed  by  some  successful  surgeons.  Gauze  pack- 
ing would  undoubtedly  have  caused  the  death  of  some  patients 
from  shock,  or  from  intestinal  obstruction,  or  from  septicemia,  or 
from  iodoform  poisoning,  if  iodoform  gauze  had  been  used,  and 
there  would  have  been  several  post-operative  ventral  hernias  at 
the  site  of  large  packed  wounds.  Several  patients  would  very 
likely  have  died  from  peritonitis  or  septicemia  if  their  abscesses, 
had  not  been  cleansed  with  hydrogen  dioxide  and  saline  solution 
before  search  was  made  for  multiple  abscesses,  and  three  patients, 
who  recovered  would  certainly  have  died  if  I  had  not  separated 
adhesions  freely  and  discovered  such  multiple  abscesses.  We 
need  not  fear  to  open  the  free  peritoneal  cavity  in  suppurative 
appendicitis  cases  if  we  do  it  safely  with  reliable  resources  at 
hand. 

In  explanation  for  the  character  of  the  results,  surgeons  who. 

162 


SubscqiLcnt  Notes  on  Appendicitis.  163 

are  not  familiar  with  my  work  have  sometimes  suggested  that  I 
might  not  have  difficult  cases  to  deal  with.  This  idea,  if  con- 
sidered seriously,  would  have  the  effect  of  diverting  attention 
from  the  vital  points  at  issue  in  the  technique,  and  consequently 
it  becomes  necessary  for  me  to  state  that  my  cases  are  like  those 
of  other  surgeons. 

Classification  of  tJic  Cases. 

Acute  appendicitis,  with  abscess 34 

Chronic  appendicitis,  with  chronic  abscess 4 

Acute  appendicitis,  without  actual  abscess 12 

Chronic  appendicitis,  without  abscess 40 

Tuberculosis  of  appendix.    6 

Cancer  of  appendix i 

Appendix  obstructed  by  torsion 2 

Uninfected  appendix,  with  concretion r 

Total 100 

Deaths 2 

Post-operative  ventral  hernias O 

Males 76 

Females 24 

Cases  with  nematode  ulceraiion 2 

Cases  with  hard  incarcerated  concretions 8 

Cases  with  total  occlusion,  damming  products  of  inflammation 12 

Cases  with  strangulation  of  bowel  from  appendix  adhesion  loop i 

Number  of  attacks  of  appendicitis  suffered  by  the  one  hundred  patients,  about.  350 
Number  of  attacks  of  appendicitis  in  the  one  hundred  patients  previously  diag- 
nosticated  and  treated  as  cases  of  colic,   bowel  obstruction,  gastric  fever, 

peritonitis,  typhoid  fever,  etc.,  about ISC' 

Estimating  that  the  i  50  attacks  diagnosticated  improperly  cost 
patients  an  average  of  twenty-five  dollars  for  treatment  of  each 
attack,  we  find  an  expenditure  of  $3,250  for  treatment  which  was 
not  aimed  at  the  real  cause  of  the  trouble. 

Abscess  Cases. 

All  of  the  acute  appendicitis  cases  to  which  I  was  called  were 
operated  upon  immediately  with  the  exception  of  two  patients, 
who  died  before  my  arrival  at  their  homes.  Of  the  thirty-eight 
abscess  cases,  thirty-six  recovered  and  two  died.  One  died  of 
suppurative  nephritis  which  was  present  at  the  time  of  operation. 
The  other  one  died  of  general  septic  peritonitis  which  was  pres- 
ent at  the  time  of  operation.  Several  patients  were  nearly  mori- 
bund with  various  degrees  of  septicemia  and  peritonitis  before 


1 64  Notes. 

operation.  One  patient  who  recovered  had  been  refused  help  by 
an  eminent  surgeon  on  the  ground  that  he  Avould  die  in  a  few- 
hours  with  or  without  surgical  interference.  In  this  connection 
I  wish  to  .say  that  we  have  all  overestimated  the  danger  in  cases 
of  general  suppurative  peritonitis.  These  cases  can  recover  as  a 
result  of  application  of  the  technique  described  elsewhere  in  the 
book.  The  principal  difficulty  seems  to  arise  from  failure  of  the 
alimentary  tract  to  do  its  work,  and  even  predigested  food  will 
sometimes  pass  out  of  the  anus  unchanged  after  the  case  is 
under  surgical  control.  Other  patients  digest  mixed  diet  and 
pass  it  out  of  the  anus  unabsorbed.  The  appendices  were  re- 
moved in  all  but  five  of  the  acute  cases.  Two  of  these  appen- 
dices had  already  sloughed,  and  in  three  cases  the  condition 
of  the  patient  forbade  any  Avork  beyond  the  most  expeditious 
opening  of  abscesses.  There  is  no  position  in  which  nicer  surgi- 
cal judgment  is  required  than  in  the  management  of  these  mori- 
bund cases  in  which  the  patient  may  die  from  shock  if  we  stop 
to  remove  the  appendix,  or  he  may  die  from  septicemia  if  we 
leave  it  in.  Three  patients  had  multiple  abscesses,  so  that  if  they 
had  been  managed  by  the  plan  of  opening  "  the  abscess  "  they 
would  have  added  three  cases  to  the  death-rate.  The  reasons 
why  we  need  not  fear  opening  freely  into  the  general  peritoneal 
cavity  in  the  search  for  multiple  abscesses  have  been  detailed 
elsewhere. 

Several  patients  with  gangrenous  appendices  had  fecal  fistulae 
after  operation.  All  but  one  of  these  fistulse  closed  spontane- 
ously, and  that  one  will  need  to  have  the  cecal  wall  infolded. 

In  one  case  in  which  the  appendix  and  nearly  all  of  the  cecum 
had  sloughed  and  pus  had  burrowed  from  the  pelvis  into  both 
buttocks,  the  remains  of  the  cecum  were  successfully  infolded 
and  united  with  Lembert  sutures. 

Four  cases  had  phlebitis  of  saphenous  veins.  The  phlebitis  in- 
volved the  left  saphenous  veins  in  three  of  the  cases  in  which 
there  was  no  evidence  of  previous  infection  on  the  left  side  of  the 
pelvis.  This  may  be  one  of  the  curious  groups  of  coincidences 
seen  in  surgery,  or  it  may  call  for  a  special  explanation. 

Acute  and  Chroizic  Appendicitis  ivitJwiit  Abscess. 

Fifty-two  cases.  Thirty-eight  of  the  cases  of  this  group  were 
operated    upon    through    the    inch-and-a-half    incision.      In   the 


Subsequent  Notes  on  Appendicitis.  165 

remainder  it  was  easier  to  work  with  more  room.  Thirteen  of 
the  cases  were  not  compHcated  by  adhesions,  ahhough  some  of 
this  number  were  of  the  most  dangerous  type,  on  the  point 
of  sloughing,  or  perforating,  or  rupturing  under  stress  of  distend- 
ing contents.  The  remainder  presented  all  of  the  various  degrees 
of  adhesion  that  are  met  with  in  "  interval  "  work.  The  appen- 
dices were  removed  in  all  but  two  of  the  acute  and  chronic  cases 
without  abscess.  In  these  two  cases  after  separation  of  adhesions 
the  appendices  were  found  to  have  dwindled  to  mere  fibrous 
strings.  Dawbarn's  method  of  inversion  of  the  stump  of  the 
appendix  is  applicable  to  a  greater  number  of  cases  than  my 
own  method,  because  it  can  be  applied  where  the  cecal  walls  are 
quite  stiff  and  fragile.  In  that  method  full  half  an  inch  of  the 
appendix  is  left.  The  stump  is  widely  stretched  by  inserting 
forceps  through  the  lumen.  The  cut  margin  is  then  seized  with 
mouse-tooth  forceps  and  inverted  into  the  cecum.  One  or  two 
sutures  close  the  dimple  that  remains. 

Tiibcrciilosis  and  Cancer  of  the  Appendix. 

In  two  cases  of  tuberculosis  and  in  one  case  of  cancer  of  the 
appendix,  the  appendices  were  removed.  In  four  cases  masses 
of  tubercle  had  replaced  the  appendices.  All  of  these  cases 
recovered  from  the  operation.  One  still  has  tuberculous  peri- 
tonitis. One  has  general  tuberculous  infection,  developed  after 
operation,  which  is  apparently  recovering  under  vigorous  creasote 
treatment. 

One  patient  who  had  general  tuberculous  infection  is  appar- 
ently recovering,  and  has  at  least  gained  weight,  strength,  and 
color  under  the  influence  of  a  nuclein  preparation. 

ObstriLction  by  Torsion. 

In  two  cases  the  appendices  had  become  twisted  upon  them- 
selves in  such  a  way  as  to  dam  their  lumens,  which  were  distended 
with  mucus.  The  patients  suffered  from  persistent  nausea  and 
discomfort  in  the  appendix  region.  The  appendices  were  proba- 
bly not  infected,  but  it  seemed  safer  to  remove  them,  although  I 
have  always  been  distinctly  opposed  to  the  idea  of  removing 
uninfected  appendices,  as  will  be  observed  by  careful  reference  to 
my  published  contributions. 


1 66  Notes. 

Estimated  Rcsii/ts  of  JMcdical  Trcatvicnt. 

If  these  one  hundred  cases  had  been  managed  without  surgery 
by  any  sort  of  medical  treatment  whatever,  the  results  could  be 
reckoned  about  as  follows  : 

Seven  cases  of  tuberculosis  and  cancer  of  the  appendix  ;  deaths 5 

One  case  of  strangulation  of  bowel  by  appendix  adhesion  band  ;  death i 

Thirty- eight  abscess  cases  ;  deaths 15 

Eight  cases  with  hard  incarcerated  concretions  ;  deaths 2 

Twelve  cases  of  total  occlusion  with  dammed  products  of  inflammation  ;  deaths.  5 

Total 28 

On  first  thought  we  may  feel  that  only  the  worst  cases  get  to 
the  surgeon,  and  that  the  medical  death-rate  would  not  have 
been  twenty-eight  per  cent. 

On  second  thought  v/e  remember  that  these  are  all  the  same 
patients  who  had  already  recovered  from  two  hundred  and  fifty 
attacks  under  medical  treatment,  without  making  any  difference 
with  end  results.  The  reason  why  it  is  morally  wrong  to  depend 
upon  any  kind  of  medical  treatment  in  appendicitis  is  thus  made 
clear  by  this  one  group  of  cases.  The  difference  between  a  sur- 
gical death-rate  of  two  per  cent  and  a  medical  death-rate  of 
twenty-eight  per  cent  is  absolute,  and  means  that  twent}'-six 
patients  would  have  been  buried  under  ground  at  the  wrong 
time.  It  means  also  that  an  insurance  company  can  insure  the 
life  of  a  patient  one  hour  before  he  is  to  undergo  a  surgical  oper- 
ation for  the  removal  of  his  appendix,  but  they  cannot  insure  his 
life  one  hour  after  he  has  been  discharged  as  cured  by  medical 
treatment.  Even  the  surgical  death-rate  of  two  per  cent  was 
unnecessary  and  could  have  been  avoided  by  following  surgical 
rules. 

Palpation  of  the  Appendix. 

A  step  in  progress  in  the  subject  of  palpation  of  the  appendix 
will  be  observed  if  we  note  that  it  is  possible  to  get  at  a  free 
appendix  that  lies  in  the  pelvis.  This  is  accomplished  simply  by 
carrying  the  cecum  so  high  cephalad  on  the  ends  of  the  fingers, 
that  the  appendix  suddenly  bobs  out  of  the  pelvis  and  under  the 
examiner's  fingers.  It  is  then  easily  rolled  about  against  the 
psoas  and  iliacus  muscles,  and  its  size  and  condition  are  easily 
made  out  if  adhesions  do  not  interfere.  Physicians  must  give 
much  more   attention    to    the    matter  of   accurate  palpation   of 


Subsequent  Notes  on  Appendicitis.  1 6  7 

the  appendix.  I  have  had  occasion  to  see  a  good  many  sus- 
pected appendicitis  cases  in  consultation  with  some  of  our 
most  expert  general  diagnosticians  who  failed  to  take  ordinary 
steps  for  getting  the  appendix  separately  and  clearly  under  their 
fingers.  It  Avas  evidently  unfamiliar  work  for  them,  and  yet  they 
were  often  depended  upon  for  an  opinion.  Physicians  who  pal- 
pate ureters  and  Fallopian  tubes  can  readily  palpate  a  normal 
appendix  on  the  lines  laid  down  on  pages  43  and  44  in  addition 
to  the  point  just  described.  We  do  not  need  exploratory  inci- 
sions to  determine  whether  a  patient  has  appendicitis  or  not. 

Traumatisvi  of  the  Appendix. 

Robinson,  of  Chicago,  has  recently  shown  that  an  atrium  for  in- 
fection of  the  appendix  must  often  be  produced  by  a  traumatism 
inflicted  by  the  right  psoas  muscle.  Any  one  who  will  first  pal- 
pate a  normal  appendix  and  then  ask  the  patient  to  contract  his 
right  psoas  muscle  will  be  instantly  convinced  of  the  importance 
of  the  theory.  To  my  mind  the  last  needful  fact  has  now  been 
demonstrated — the  testimony  is  all  in,  and  the  etiology  and 
pathology  of  infective  appendicitis  are  thoroughly  understood. 

We  know  the  etiology  and  the  pathology.  We  know  how  to 
reduce  the  death-rate  to  a  fraction  of  one  per  cent.  Robinson 
explains  that  sigmoiditis  may  follow  the  infliction  of  a  trauma- 
tism upon  the  sigmoid  flexure  of  the  colon  by  the  left  psoas 
muscle.  Sigmoiditis  is  a  disease  that  has  been  pretty  generally 
overlooked,  until  the  widespread  knowledge  about  appendicitis 
enabled  patients  to  say  that  they  had  all  of  the  symptoms  of 
appendicitis,  but  on  the  left  side.  The  sigmoid  flexure  injured 
by  the  psoas  muscle,  angulated  by  bagging  into  the  pelvis,  and 
irritated  by  obstructed  scybala,  may  become  infected  and  remain 
the  seat  of  chronic  inflammation;  or  it  may  perforate  and  cause 
fatal  peritonitis.  Although  sigmoiditis  is  rather  common,  and 
has  been  given  full  and  comprehensive  description  by  some 
authors,  most  of  the  standard  text-books  make  no  mention  of  it. 

Rheumatism  has  been  recently  spoken  of  as  a  cause  for  some 
cases  of  appendicitis.  It  probably  has  no  influence  in  the  pro- 
duction of  infective  appendicitis  excepting  when  it  is  responsible 
for  proliferating  endarteritis  of  the  solitary  artery  of .  the  appen- 
dix, or  when  it  causes  intestinal  fermentation  with  production  of 
appendix  concretions.  I  have  seen  in  consultation  some  cases  of 
rheumatic  or  gouty  inflammation  of  the  lymphoid  tissues  of  the 


1 68  Notes. 

colon  and  appendix,  but  these  are  not  infective  cases.  I  do  not 
classify  them  with  true  appendicitis,  and  they  are  very  readily 
differentiated  from  true  infective  appendicitis  cases  by  any  one 
who  pretends  to  be  at  all  expert.  I  have  also  seen  many  cases 
of  chronic  appendicitis  with  rheumatoid  symptoms,  due  to  sep- 
ticemia, but  they  were  no  more  cases  of  rheumatism  than  cases 
of  gonorrhceal  septicemia  are  cases  of  rheumatism.  In  a  person 
of  gouty  or  rheumatic  diathesis  a  chronic  infection  of  the  appen- 
dix which  caused  functional  derangement  of  the  digestive  organs 
might  be  expected  to  increase  the  tendency  to  exacerbations  of 
the  rheumatism  or  gout. 

The  inch-and-a-half  incision  is  now  employed  by  a  number  of 
operators  who  are  familiar  with  adhesion  work.  I  could  not 
understand  at  first  why  there  was  such  general  objection  to  a 
pretty  and  successful  operation,  until  it  became  evident  that  I 
had  made  a  mistake  in  assuming  that  all  surgeons  were  equally 
at  home  among  adhesions.  Gynecologists  who  deal  much  with 
pyosalpinx  find  the  short-incision  method  an  easy  one  in  appen- 
dicitis cases,  and  objections  all  seemed  to  come  from  surgeons 
who  had  not  really  seen  or  tried  the  short-incision  method  in 
accordance  with  the  details  which  I  had  carefully  described. 
The  argument  that  the  short-incision  method  is  dangerous  arises 
from  preconceived  ideas  of  what  it  is  like,  but  the  case  can  be 
rested  on  the  testimony  of  statistics  to  date. 

THE  FORMALIN  PREPARATION  OF  CATGUT. 

A  recent  article  by  Vollmer  on  the  formalin  preparation  of  cat- 
gut, Centralblatt  fur  Gyncskologie,  No.  46,  1895,  and  a  paper  by 
Fish  on  the  use  of  formalin  in  neurology.  Proceedings  of  the  Mi- 
croscopical Society,  volume  xvii.,  1895,  led  me  to  take  up  this 
simplest  of  all  methods  for  the  preparation  of  catgut.  Formalin 
(HCHO)  is  the  commercial  name  for  a  forty-per-cent  solution  of 
formic  aldehyde  gas  in  water,  and  it  is  prepared  by  subjecting 
methyl  alcohol  to  oxidation.  Formalin  is  a  penetrating  germi- 
cide and  hardening  agent  for  animal  tissues. 

Raw  impure  catgut  placed  in  a  two-per-cent  watery  solution 
of  formalin  is  sterilized  and  hardened  in  a  few  hours,  but  the 
hardening  process  begins  so  quickly  that  the  catgut  does  not 
swell  as  it  would  in  water  alone.  According  to  authors  who 
have  tried   this  method  of    preparation   the   catgut  is  sterilized 


Subsequent  Notes  on  Appendicitis.  1 69 

but  is  rendered  too  brittle.  Apparently  we  may  obviate  the  lat- 
ter objection  by  a  final  treatment  of  the  catgut  with  alcohol. 
As  formalin  and  bichromate  of  potassium  are  not  incompatible  in 
solution  I  prepared  catgut  by  placing  it  in  water  containing  ten 
minims  of  formalin  and  one  grain  of  bichromate  of  potassium  to 
the  ounce,  leaving  the  catgut  in  the  solution  for  twenty-four 
hours.  It  was  then  washed  in  a  large  dishpan  full  of  boiled 
water  for  ten  minutes  to  remove  the  irritating  formalin,  spread 
out  to  dry  between  two  sterilized  towels,  and  finally  stored 
in  absolute  alcohol.  Formalin  catgut  can  be  boiled  a  little 
without  much  injury,  but  it  is  best,  perhaps,  to  simply  wash  it  in 
water  that  has  been  recently  boiled.  In  order  to  test  the  tensile 
strength  of  the  catgut  I  experimented  by  subjecting  strands  of 
the  material  to  tension  on  the  hook  of  a  spring  balance,  mean- 
while watching  the  indicator  to  note  breaking  points.  In  each 
test  a  strand  of  No.  18  American  Avire-gauze  catgut,  one  metre  in 
length,  was  folded  once  upon  itself,  the  ends  were  tied,  and  one 
end  of  the  loop  was  hung  over  a  door  knob. 

One  strand  dry  unprepared  catgut  broke  at  pounds  pull 36 

One  strand  prepared  by  boiling  in  alcohol,  hardening  in  bichromate  of  potas- 
sium, and  storing  in  alcohol,  broke  at  pounds  pull 32 

One  strand  prepared  in  two-per-cent  formalin  for  twenty-four  hours,  washed  in 

tepid  water,  and  stored  in  alcohol,  broke  at  pounds  pull 40 

One  strand  prepared  in  formalin  and  bichromate  of  potassium  solution,  washed 

in  tepid  water,  and  stored  in  alcohol,  broke  at  pounds  pull 40 

One  strand  prepared  in  formalin  and  bichromate  of  potassium  solution,  washed 

quickly  in  boiling  water,  and  stored  in  alcohol,  broke  at  pounds  pull 50 

Such  a  test  is  necessarily  inaccurate,  but  it  indicates  that  cat- 
gut prepared  according  to  this  description  is  not  brittle. 

Some  months  must  elapse  before  complete  tests  showing  the 
resistance  of  this  catgut  to  absorption  in  the  tissues  can  be  made, 
but  I  hope  to  describe  later  the  preparation  of  graded  lots  of  cat- 
gut which  will  be  absorbed  in  estimated  lengths  of  time. 


INDEX. 


Abdominal  wall,  repair  of,  109 
Abortion,  prevented,  154 
Abscess,  28,  2g,   30,  63 
Adhesion  separation,   30,  63,  58 

"         bands,  30,  35 
After  treatment,  appendicitis,  67 
Appendicitis,  definition,  16 

"  causes,  16 

"  occurrence,  34 

"  catarrhal,  33 

"  nomenclature,  35 

"  aliases,  40 

"  symptoms,  41,  42 

"  structures  involved,  17 

Appendix,  occurrence  of,  10 

"  history,  1 1 

"  size  and  position,  11 

"  anatomy,  12 

"  involution,  35 

"  locating,  58 

Aprons,  6 
Aristol,  6,  60 

Arm,  conservative  surgery  of,  146 
Arterial  complications,  13,  24 


B 


Bacteria,  of  appendix,  15 
"         suicide  of,  20 
"  odor  of,  21 

Blister  grafting,  151 

Blood  clot  replacement,  1 61 

Boiled  water,  5 

Bow  lines,  4 

C 

Carious  and  necrotic  bone,  123 
Catgut,  3,  168 


Chemical  antiseptics,   5 
Circulation,  interference,  18,  19 
Clavicle,  dowel-pin,  dislocation,  139 

"  "  fracture,  140 

Colic,  42 

Compensatory  hypertrophy,  33 
Compression  anemia,  8,  9 
Concretions,  13,  39 
Constipation  and  diarrhoea,  45 
Cotton,  3 
Culture  tubes,  6,  7 

D 

Death  rate,  appendicitis,  36 
Digestive  ferments,  120 
Dislocation  of  appendix,  25 
Drainage  apparatus,  3 

"  canal,   59 

"  capillary,   64,  66 

"  wick,  115 


Eczematoid  navel,  92 
Embryonic  remains,  92 
Endarteritis,  25 
Endoscopic  tubes,  117 
Evanescent  scar,  60 
Exudate,  liquefaction  of,  27,  30 


Facies,  45 

Fat  layers,  union  of,  61 
Fat  tests,  13,  14 
Fibula,  fractures,  136 
Fistulse,  plaster,  154 
Fulgurant  spasm,  44 


172 


Index. 


GalLstone  solvents,  84 
Gauze,  2,  3 

General  abdominal  pain,  42 
General  cleanliness,  i 
Guy  line,  55 

H 

Hand  sterilization,  r 
Harelip,  153 
Hepatic  abscess,  24 
Hernia  operation,  gS 
Hernia,  post  operative,  50 
Hydrogen  dioxide,  5,  63,  67 

I 

Ileal  intussusception,  100 
Incision,  51-54,  56,  62,  168 
Infection,  acute,  effects,  17,  18,  20 

"         atrium,  17 

"         chronic,  20,  33 
Instruments,  sterilization,  2 
Inversion  of  uterus,  155 
Irrigating  solution,  5 
Isolation  of  infected  appendix,  36 


Leaving  infected  appendix,  28,  64 

Ligatures,  3 

List  of  appendix  operations,  68,  163 

List  of  general  operations,  8,  g 

Localized  pain,  45 

Lymph,  blocking,  23 

Lymph  exudate,  46 

Lymphatitis,  infective,  24 

M 

Malignant  disease,  navel,  g4 

Mallet-finger,  143 

McBurney's  point,  43 

Medical  treatment,  appendicitis,  37,  166 

Moist  navel,  g2 

Muscular  spasm,  19,  37,  43,  45 

N 

Nasal  septum,  plastic,  153 
Nausea  and  vomiting,  43 
Nephritis,  as  complication,  31 


Nerve  complications,  26 

Nervous  dyspepsia,  40 

Normal  appendix,  removal  of,  38 

O 

Objections  to  operation,  49 

Omental  rope,  31 

Opium,  37,  38 

Ovarian  transplantation,  156 

Ovaritis  and  appendicitis  compared,  39 


Palpation  of  appendix,  43,  44,  166 

"  the  kidney,  107 
Pathology  and   etiology   of  appendicitis, 

16,  167 
Pendulum  simile,  39 
Perforation,  28 
Peritoneum,  aid  given  by,  27 
Peritonitis,  complicating,  26,  2S 
Phagocytosis,  ig,  20 
Phlebitis,  24,  26 
Placental  hemorrhage,  155 
Pleuritis,  complicating,  32 
Pneumonitis,  complicatmg,  32 
Policy  in  operating,  3g 
Prevention  of  peritoneal  adhesions,  105 
Progress,  recent,  37 
Pulse,  in  appendicitis,  23,  44,  46 
Pus  in  peritoneal  cavity,  27 

R 

Radius,  subluxation,  132 
Repair,  time  required  for,  ^i 
Respiration,  45 
Reversed  peristalsis,  58 
Rheumatism  and  appendicitis,  167 
Rhexis,  34 
Robinson's  theory,  167 


Salol,  I, 

Scar  testing,  52 

Scars,  51,  62 

Serum  pressure,  17 

Sigmoiditis,  167 

Silk,  3 

Skin,  sterilization,  i 

Sloughs,  24 

Special  cleanliness,  i 


Indc: 


:x. 


/o 


Sponges,  2 

Stomach  and  rectal  tubes,  67,  6S 

Stump,  burial  of,  59 

"  fixation  to  abdominal  wall,  59 

"  ligation  of,  50 

Supra-pubic  urethra,  112 
Sutures,  3 


Tonsil,  flat  and  tubular,  17 
Towels,  2 

Toxines,  effects  of,  ly,  iS,  46 
Treatment,  appendicitis,  surgical,  49 
Trendelenburg's  posture,  62 
Tuberculosis,  peritoneum,  102 
Tubes,  appendix,  inner  and  outer,  17 
Typical  case,  42 


Temperature  in  appendicitis,  22,  44,  46 
Time  spent  in  bed,  52,  67 


U 


Ulceration  of  appendix,  25 


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